Home Health & Hospice Week

Prepare to tackle confusion as billing switches to 30 days, but other requirements don’t.

One of the many reasons PDGM will hit home health agencies hard is the increase in the billing-related workload under the new payment system.

Commenters on the 2020 proposed rule for home health payment run down the many problems the Patient-Driven Groupings Model will cause in the billing arena when it switches payment from 60-day episodes to 30-day periods of care.

Foremost among the downsides is the sheer workload increase. The Centers for Medicare & Medicaid Services “is proposing to require agencies to revise their operations from a ‘two claim’ billing cycle to a ‘four claim’ billing cycle” every 60 days, points out Brad Hollinger, CEO of Vibra Healthcare and Ernest Health in Pennsylvania, in his comment letter.

“These changes will significantly increase administrative burden and costs,” warns Effie Bassett in Texas in her comment letter.

The switch to 30-day periods will boil down to “more frequent claim submissions,” explains Brenda Goosby, director of Mad River Community Hospital Home Health Services in Arcata, California. “This means more RAPs and more final claims. The billing office is projected to increase by 50 percent,” Goosby tells CMS.

Doubling agencies’ billing work under PDGM goes against Patients over Paperwork principles of streamlining red tape in Medicare, multiple commenters pointed out.

With the change will come confusion, warns Candy Bartlett with Aegis Therapies in Florida. “A 30-day payment period … ignores other existing Medicare provisions governing the delivery of home health services which will continue to be tied to a 60-day period,” Bartlett says in Aegis’ comment letter. “These include the patient plan of care, physician certifications of eligibility, and OASIS assessments. Payment periods which are inconsistent with the rest of Medicare home health provisions will unnecessarily create additional administrative burdens and costs.”

Plus: HHAs will need to spend time educating both their own staff and others they work with on the change and how it interacts with the 60-day elements.

The problems due to workload increase and confusion will be compounded by the speed with which the switch to 30-day periods take place, multiple commenters charge.

“Insufficient transition time” will contribute to unnecessary mistakes on the part of HHAs and resulting extra burdens to Medicare contractors with increased appeals, Bartlett cautions. “Such action in the face of an already overburdened appellate process within the Office of Medicare Hearings and Appeals seems counterproductive at best,” the Aegis letter notes.

HHAs “need time to understand the final changes, train clinical staff in how best to manage care under these new measures, train billing staff as we work with our health information technology vendors to produce acceptable claims and determine what we need as an agency to stay viable,” Goosby argues. “Twenty years ago, when CMS transitioned from fee for service to PPS, we had an Interim Payment System, that helped transition this change.”

All of the negatives of the 30-day period will add up to creating access problems for Medicare beneficiaries who need home care, especially in areas lacking a robust HHA population, commenters warn CMS. “This change represents a challenge for already tight budgeting in home health agencies across the country and will significantly impact not only their financial viability, but also their ability to continue to deliver high quality care to their patients,” Goosby stresses. “It could also cause some agencies to reduce or even eliminate their provision of Medicare services, thus restricting access to patients, particularly in rural and inner-city areas.”

With PDGM, “CMS is particularly threatening the viability of smaller, local agencies that are thinly capitalized, but that in some areas of our state are essential community providers,” says the Home Care Alliance of Massachusetts.

Temper PDGM’s Harm

Aegis acknowledges that the switch to 30-day billing periods under PDGM is mandated by the Bipartisan Budget Act of 2018 (see Eli’s HCW, Vol. XXVII, No. 7). Thus, that element of PDGM can only be changed by another law

But CMS can make implementation more gradual and can try to minimize burden in other areas (especially the 8.01 percent behavior adjustment cut) to compensate for the hardship caused by the mandated billing period change.

“Eight percent may not look like a lot, but it is enormous to us,” says Ronnie Thomas in Florida, who is both a home health worker and a Medicare recipient.

Do this: Mad River urges CMS to consider a transition phase similar to IPS in the late 1990s, “so that this untested new model can be fully understood at all points and not be part of destabilizing our agency’s future,” Goosby says.