Home Health & Hospice Week

Will fewer comment letters mean fewer concessions?

It’s surely no surprise to Medicare officials that home health agencies commenting on the 2020 home health payment rule are staunchly opposed to the Patient-Driven Grouping Model’s preemptive behavioral adjustment cut. But home health providers hope the volume and intensity of their feedback will make it hard for the Centers for Medicare & Medicaid Services to ignore the potentially disas- trous consequences of the steep adjustment.

Background: Back in July, CMS issued the 2020 proposed rule, which included a behavioral adjustment set at a whopping 8.01 percent (see Eli’s HCW, Vol. XXVIII, No. 25-26). That was up from an estimated 6.4 percent in the previous year’s rulemaking cycle. CMS said the cut would compensate for changes home health agencies would make in their coding and other practices, including maximizing reimbursement by changing primary diagnosis codes, including more comorbidity diagnosis codes, and adding visits to avoid Low Utilization Payment Adjustments in the new 30-day billing period.

More than 550 interested parties commented on the 2020 rule, with the most popular topic for comment the adjustment. While that amount far exceeds the number of comment letters on the proposed payment rules in 2014 (364 letters), 2015 (120 letters), and 2016 (89 letters), it’s less than half of the number of letters received when PDGM’s predecessor, HHGM, was introduced in 2017 (1,350 letters) and PDGM itself was proposed in 2018 (1,345 letters).

HHAs were likely resigned to PDGM getting pushed through mainly as proposed, suspects attorney Robert Markette Jr. with Hall Render in Indianapolis. “We mustered a huge level of response the last two years and basically got ignored,” Markette tells Eli. “I am not surprised that we didn’t generate as many comments this year.”

Nevertheless, many providers and industry representatives this year took aim at the concept of making a payment adjustment — especially such a significant one — before PDGM even takes effect. “There is no authoritative evidence that home health agencies have or will deliberately miscode,” insists Franklin County Home Health Agency Inc. in Vermont, in its comment letter. “CMS has not used behavioral adjustments in any other health care setting, including SNFs under PDPM, as a prospective tool for controlling cost. CMS is singling out home health and could affect access to patient care in the future,” the agency criticizes.

CMS has no evidence that the assumed provider changes “may actually occur,” charges Eric Keiper with Sooner Home Health in Oklahoma. “My home care agency has been basing patients’ care plans on what its patients need. We have not been gaming the system, will not do so, and should not be subjected to payment cuts based on Medicare’s faulty assumptions,” Keiper insists.

“Any behavioral adjustments should be based on actual behavior — not anticipated action,” stresses Kathryn McGuire of BayCare HomeCare in Largo Florida, in the agency’s comment letter. “A retrospective, data-driven behavioral adjustment would provide a more equitable solution, and we urge CMS to consider this approach,” McGuire says.

“Without clarity and actual substantiation of assumed ‘behavioral adjustment,’ this 8.01 percent reduction in reimbursement should not exist at all in the first year of PDGM,” urges Pat West with Pioneer Home Health Care Inc. in Bishop, California. “Please withdraw the proposed behavioral adjustment. Then, use relevant and reliable data from 2020 and each successive year to determine if any adjustment is required,” West says.

“We believe it entirely unreasonable for CMS to assume over four times the average annual change that was experienced in the 2000 transition to the current HHPPS model, especially given that PDGM has fewer meaningful areas of behavior change risk than existed in the 2000 model,” says the Home Care Alliance of Massachusetts in its comment letter. “In both overstating the risk of behavior change and implementing such a radically different payment model requiring considerable training and operational resources at every agency, 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.”

Many commenters repeated the idea that the cut, and other rule provisions, will weigh heavily on small independent agencies (see related story, p. 274).

For example: The behavioral cut “will most certainly put small locally owned agencies, such as us, out of business,” warned the owner of All Coast Therapy Services Inc. in the agency’s comment letter. “Please reconsider the behavioral adjustment of 8.1 percent and give us small honest providers a chance to make it through.”

What’s ahead: The comment period for the proposed rule closed earlier this month. Home health agencies will see whether CMS heeds its comments when the final rule is published, likely in late October or early November.

Note: The proposed rule is at www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14913.pdf.