Home Health & Hospice Week

Your PDGM training has only just begun.

You might feel like your world has been turned upside down under the drastic new payment model that took effect Jan. 1, but you can take steps to make sure you survive — and thrive — in the new environment.

The Patient-Driven Groupings Model is challenging home health agencies on multiple fronts ranging from therapy provision to cash flow to intake processes (see Eli’s HCW, Vol. XXIX, No. 6). And agencies that don’t get on top of the problems may become part of the crowd expected to go belly up under PDGM (see related story, p. 53).

Follow this expert advice to avoid that fate and become a PDGM success story:

1. Education. Before you can tackle your PDGM-sparked problems, you need to understand them. There’s been a “surprising lack of education,” especially “among the smaller providers,” judges industry veteran Tom Boyd with Simione Healthcare Consultants in Rohnert Park, California. Education and awareness are “key to survive,” Boyd stresses.

Now that PDGM is in full swing, “do not let up on PDGM education,” urges Sharon Harder, president of consulting firm C3Advisors in Wheaton, Illinois. That education will take varied forms.

For example: “Read everything that comes out from [the Centers for Medicare & Medicaid Services] as new guidance is still emerging,” Harder advises. One example is the January 2020 OASIS questions-and-answer set with guidance on determining the M0090 date (see Eli’s HCW, Vol. XXIX, No. 5). “PDGM is still something of a moving target — we shouldn’t forget that,” she emphasizes.

In addition to educating themselves, home health leaders should be educating their staff.

Tip: “When the educational content is scenario-based … this will help in providing answers to some of PDGM’s more intricate questions or situations,” Harder says. “Agencies should start building their own scenarios as a means of determining underlying agency policies, procedures, and process refinements.”

2. Billing. Low Request for Anticipated Payment levels combined with 30-day billing periods means your billing process must be as efficient as possible under PDGM. “We are now reaching the point where those initial PDGM payment periods are ending and patients receiving care beyond day 30 are moving into a second payment period,” observes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. “Now is definitely the time to be focusing on the revenue cycle by making sure the documentation from the initial payment periods is complete and related physician orders are signed so those corresponding claims can be billed.”

Under PDGM, the billing process requires many different components — valid primary and secondary diagnosis codes, accurate admission source information and corresponding occurrence codes on the claim, signed physician orders, adequate face-to-face physician encounter documentation, confirmation of successful OASIS submission, etc. “There is so much that needs to be done before dropping that first 30-day claim,” notes Julianne Haydel with Haydel Consulting Services and The Coders in Baton Rouge, Louisiana.

Securing timely signed orders from physicians is causing agencies big headaches, notes Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan.

Simultaneously, agencies need to be hopping on the next billing period. That requires “focusing on the process needed to confirm whether any updates are needed for diagnosis coding or community/institutional designations on the period-two RAPs so that those can be getting billed as timely as possible,” Little recommends.

3. Diagnosis coding. Your PDGM success depends on your coding accuracy. Prioritize coding concerns in education and process overhauls (see details in story, p. 51).

4. Intake. Diagnosis coding isn’t the only vital piece of information your intake staff must collect. Admission source, F2F, and other clinical factors are also essential. “Intake staff will need to learn how to request valid information up front,” the emphasizes the Home Health Certificate Course from the professional coding association AAPC. “Agencies will need to provide processes and tools to support the gathering of adequate information.”

5. Cash flow. All of your streamlined intake and billing processes should be in service of ensuring cash flow. If you can’t make payroll, the rest of your PDGM preparation is for naught.

For agencies “without the necessary credit capacity, PDGM is going to be life threatening to be sure,” Harder warns.

Cash flow budgeting should be a focus under PDGM, Boyd maintains. (Reminder: A cash flow budget is an estimate of all cash receipts and all cash expenditures that are expected to occur during a certain time period.)

Ensuring adequate cash flow “generally boils down to getting documentation required for billing out the door and back quickly to enable billing,” Harder says.

Beware these obstacles: Boyd expects HHH Medicare Administrative Contractor Targeted Probe & Educate (TPE) audits “to be adding to cash flow problems” under PDGM, he says. The Review Choice Demonstration will also significantly impact cash flow in RCD demonstration states, experts add.

6. Case management. Tying all of the clinical, operational, and financial details of PDGM is a herculean task. But HHAs can create their own heroes to take it on — case managers.

HHAs should use a case management model “to maximize efficiency and visit frequencies,” Harder recommends.

“A team or case management model is a key element in clinical episode management,” stresses the AAPC Course authored by Sharon Litwin of 5 Star Consultants. “A case management model ensures that the team caring for a patient, working with a clinical manager, is being goal-oriented, proactive, planning visits together, etc.”

Plus: “The management team ensures that reports are run in real time and monthly to identify visits per team, patient, discipline, LUPAs, etc.,” the Course says. Then team management can “drill down to identify issues.” (For more LUPA advice, see story below.)

7. Therapy. CMS has made clear that HHAs shouldn’t be arbitrarily slashing therapy visits and promises to monitor utilization statistics for potential problems. However, HHAs aren’t wedded to their pre-PDGM therapy utilization either, with CMS encouraging efficiency and outcomes improvement in many areas. (See more on therapy management in Eli’s HCW, Vol. XXIX, No. 6).

8. Claims review. How do you know if your claims and documentation are meeting PDGM requirements unless you check? “Providers should focus on internal claim reviews,” Boyd counsels.

HHAs also “should conduct some self-audits to ensure consistent treatment of like kind patients between 2019 and 2020,” whether for therapy-focused or other episodes, Boyd recommends.

9. Diversify referrals. Getting buried in the details of PDGM operations and billing, HHAs might forget to take a step back to look at the big picture.

A varied patient census is good protection against payment system changes. “Some agencies have prepared by looking for different referral sources,” shares Kyle Johnson, owner and director of coding operations with Home Health Coding Solutions in Brigham City, Utah. That results in more patients on service “that have critical care needs or wound care needs, as these are some of the top PDGM HH revenue categories.”

You may also want to take a look at your revenue and/or profitability by payer and bulk up your most lucrative lines of business.

10. Nail down revenue recognition method. The onset of PDGM has also brought a debate over “how do handle the revenue recognition for the new 30-day payment periods while still having the 60-day episode of care,” notes BKD’s Mark Sharp.

The consensus: “Recognizing the PDGM revenue at 1/30 per day over each 30-day payment period is appropriate,” Sharp tells Eli.

Or: Some HHAs “are taking the approach of the average length of stay per payment period as the methodology for revenue recognition,” Sharp adds. “This method is a little more complicated under PDGM, but still doable.”

11. Tailor your PDGM plan. Each agency’s challenges under PDGM will be different, and thus their action plan to combat those areas will also vary. You first must identify “what is working and not working,” and strategize accordingly, Johnson recommends.

For example: If therapy utilization is off track, perhaps your Director of Nursing will need to work with the therapists on individualizing care plans, Johnson offers. If final billing period claims are delayed, your Administrator may have to work with the biller and field staff on timeliness. If your patient mix is unprofitable under PDGM, consider having the marketing department look at other revenue sources like wound care clinics, cardiology-specific clinics, etc.

Whatever your PDGM stumbling block is, you must first identify it, then address it.

12. Stay tuned. Processing of the first big wave of final claims under PDGM has just begun. “Most billers haven’t felt the impact yet” of PDGM, judges J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama.

“As final claims start to roll through in February and March, things might get a little more ‘interesting,” Harder warns.

Don’t be surprised if billing hardships turn into agency closures (see related story, this page).

Note: AAPC’s Home Health Certificate Course will be available at www.aapc.com.