Home Health & Hospice Week

Plus: See how much Medicare’s behavioural adjustments are stripping from base rate.

If you thought your home health agency impact file outlining the Patient Driven Groupings Model’s effects is the full story, think again.

Reminder: When the Centers for Medicare & Medicaid Services issued the 2019 Home Health Prospective Payment System proposed rule on July 2, it also offered agency-specific impact files to providers (see Eli’s HCW, Vol. XXVII, No. 26). “To support an assessment of the effects of the proposed PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS proposed and final rules,” CMS said in a fact sheet about the rule.

Providers can request the file by following the instructions at www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-Disclosures-Data-Agreements/DUA_-_NewLDS. html.

“This file will contain information from claims data matched with assessment data for CY 2017,” CMS explains in the rule. “The file will also contain variables that show the case-mix group that a particular claim would be grouped into under both the new PDGM case-mix methodology and the current case-mix adjustment methodology as well as variables for all the assessment items used for grouping the claim into its appropriate case-mix group under the PDGM and variables used for calculating resource use.”

CMS has also posted a “PDGM Agency-Level Impacts File” at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices-Items/CMS-1689-P.html. The file breaks down impacts by state, facility type, ownership type, census division, and nursing/therapy visits ratio.

An attendee of CMS’s July 11 Home Health Open Door Forum asked if CMS includes its behavioural assumption adjustments in the agency impact files. A CMS official said those adjustments are not part of the files.

Don’t forget: Those behavioral assumption adjustments are not minor. CMS plans to adjust rates downward by 6.42 percent for expected case mix creep (4.28 percent), upcoding for comorbidities (0.38 percent), and Low Utilization Payment Adjustment gaming (1.75 percent), according to the rule (see Eli’s HCW, Vol. XXVII, No. 24-25).

Episodic rate impact: Without those assumptions, CMS would put the base episodic payment rate at $1,873.91 for the first year of PDGM in 2020. With the assumptions, the 30-day base rate falls to $1,753.68, CMS notes in Table 33 of the rule.

Another caller asked how CMS arrived at the 30-day episodic base rate before assumptions.

In last year’s Home Health Groupings Model proposal, CMS planned to roughly split the current HH PPS 60-day base rate in half, noted a CMS representative in the call. But this year, Congress required CMS to make the payment reform proposal budget neutral. Therefore, CMS has to increase the PDGM 30-day rate to more than half of the proposed 2019 60-day base rate of $3,151.22.

In other words, if the Bipartisan Budget Act of 2018 didn’t require budget neutrality, you’d be looking at a 30-day base rate under PDGM of more like $1,725.61. With another 6.42 percent off for the behavioral assumptions, that would come in around $1,614.83 — $138.85 under CMS’s proposed PDGM 30-day rate of $1,753.68.

Other than offering the assumptions and methodology clarification, CMS didn’t have much opportunity to provide further elaboration about the proposed rule. The question-and-answer session of the Forum call was much shorter than usual due to the length of the CMS speaker presentations.