Home Health & Hospice Week

Patient refusals and staff shortages top the list.

Although an increase in LUPA rates was largely expected under PDGM, the LUPA surge caused by COVID-19 was not.

To get an idea of how to manage the rise in Low Utilization Payment Adjustments, home health agencies need to understand what’s contributing to the sharp upward trend, industry experts say. Some of these factors may seem obvious, while others aren’t:

• Patient visit refusal. The contributing factor that seems to be leading the way in LUPA increases is patients refusing visits. LUPAs were always going to rise under the Patient-Driven Groupings Model’s shorter 30-day episode. But “the LUPA issue is driven by COVID-19,” observes attorney Robert Markette Jr. with Hall Render.

“Fear of infection is causing patients to refuse services and/or significantly limit the visits from one or more of the disciplines,” says physical therapist Cindy Krafft with Kornetti & Krafft Health Care Solutions.

In consultant Pam Warmack’s area of Texas and Louisiana, “it began in the third week of March and got worse and worse,” reports the consultant with Clinic Connections in Ruston, Louisiana. “It was individual patients and family members requesting visits be ‘delayed’ until the virus pandemic was over. Of course I don’t think they realized how long this public health emergency was going to continue.”

But it’s not just in COVID-19 hot spots that LUPAs are increasing. Consultant Sherri Parson with Quality in Real Time in Floral Park, New York, has “seen a rise in LUPAs across the board,” she says.

• Staff shortages. The volume of visits missed due to staff issues is also “quite high,” Markette says. “A surprising number of staff … are afraid to perform home health visits, for fear of contracting COVID-19. This can lead to missed visits and LUPAs.”

Lack of child care while schools are out is also keeping some home health staff off the job.

• Facility access. “Assisted Living Facilities began ‘shutting in’ and not allowing home health clinicians to make visits,” Warmack recounts. The same goes for other types of facilities, although the Centers for Medicare & Medicaid Services did specify in a memo to state surveyors, and then in a followup frequently asked question set, that skilled nursing facilities should allow home health and hospice clinicians in (see Eli’s HCW, Vol. XXIX, No. 17).

Even when facilities allow home health and hospice staff access, they sometimes mandate that agencies “must reduce to a core service” to limit exposure, notes consultant Karen Vance with BKD.

“We are not ‘visitors’ that should be limited or denied access, but are an essential physician ordered service,” Krafft maintains.

• Preserving PPE. Even when agencies have patients willing to let clinicians in and staff willing to go, they have been hampered by a lack of personal protective equipment. “As COVID-positive patients began to be discovered and referred to home health, the agencies had to categorize essential versus nonessential visits in order to preserve their very, very limited PPE resources,” Warmack relates. “So ‘non-essential’ visits were delayed or omitted, and the LUPA problem had another layer of effect added.”
• COVID homebound definition. In its first interim final rule with COVID-19 changes, CMS loosened the definition of homebound, for home health eligibility purposes. Under the rule, patients can “be considered ‘homebound’ if it is medically contraindicated for the patient to leave the home,” it says. That applies when a physician has determined that it is medically contraindicated for a beneficiary to leave the home because she has a confirmed or suspected diagnosis of COVID-19, the rule states (see Eli’s HCW, Vol. XXIX, No. 12-13).

Once such patients “test negative, they may no longer require home care,” Parson offers. “There could be many of these with a low number of visits,” she cautions.

However, another new homebound clause may catch some of these patients. Under the new definition in the interim final rule, a physician may also determine that it is medically contraindicated for a beneficiary to leave the home because the patient has a condition that may make them more susceptible to contracting COVID-19, thus making the patient homebound.

• Therapy visit reduction. HHAs may overlook one factor contributing to LUPAs — the reduction of therapy visits under PDGM. “CMS claimed when developing the groupings model, that HHAs were increasing their therapy visits for revenue,” Parson points out. If that’s the case, now that PDGM cuts therapy utilization out of the case mix calculation, some agencies may be furnishing fewer therapy visits, which will sometimes put them under the LUPA threshold.

Note: The SNF FAQ is at www.cms.gov/files/document/qso-20-28-nh.pdf. The interim final rule is at www.govinfo.gov/content/pkg/FR-2020-04-06/pdf/2020-06990.pdf.