Home Health & Hospice Week

Don’t fall behind in PDGM prep.

If you aren’t in the midst of serious preparations for the Patient-Driven Groupings Model, you could flounder — and even sink altogether — once the new payment model hits Jan. 1.

The PDGM changes are “big and sweeping,” acknowledges attorney Robert Markette Jr. with Hall Render in Indianapolis. They are “overwhelming” to many home health agencies.

Nearly every element of the prospective payment system will undergo change in the new payment model, notes Joe Osentoski, reimbursement recovery & appeals director with Quality in Real Time in Troy, Michigan. PDGM will change pay based on episode timing, referral source, diagnoses’ relationship to reimbursement, functional assessment, and more, Osentoski points out.

There are “always those providers who stick their heads in the sand and avoid facing change,” says consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. “They better not do so this time.”

To make sure you swim instead of sink under PDGM, follow this expert advice on what you can do now to prepare for the new payment model:

1. Solidify your PDGM knowledge. At this stage, you should be familiar with all of the changes PDGM is bringing to home health payment. But if you need to catch up, or just refresh your memory, links to the 2019 PPS final rule and the Centers for Medicare & Medicaid Services’ Feb. 12 call on the model are at www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html.

2. Analyze PDGM’s impact on your agency. The new payment model brings many generalizations — high-therapy patients will lose payment, patients coming from hospitals will pay less, etc. But you won’t know how PDGM will affect you until you actually run your specific numbers.

With less than eight months to go, HHAs “should be in the process of identifying the overall impact of the PDGM system,” advises Rick Ingber with VantaHealth Consulting in Ardmore, Pennsylvania. And they must also be “drilling down on what specific issues are causing decreases and increases in reimbursement,” Ingber urges.

Specifically: You should analyze your current patient population for Low Utilization Payment Adjustment (LUPA) rate, utilization, therapy usage, primary diagnoses, episode timing, referral sources, and OASIS scoring in the functional area, Osentoski recommends. “These will provide, with analysis, context to which agency processes need to receive more attention to prepare for PDGM,” he tells Eli.

You can analyze impact on a case-by-case basis too, Warmack offers. “I have advised my clients to begin using the PDGM grouper with each SOC and recert to get a feel for how the new score would affect their decisions in utilization,” she says. “They should begin to learn which diagnoses are not capturing case weight points.”

Pay attention to referral source and patient demographics especially when performing a gap analysis, advises consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama.

3. Get organized about your changes. Your specific analysis of how your agency will fare under PDGM will inform your preparation plan. And that process shouldn’t be haphazard. “It would be a good idea to have a small committee to coordinate analysis and policy updates as necessary,” says Diane Magrady, compliance lead with Morton Grove, Illinois-based Pragma-IT, creator of the therapyBOSS therapy documentation software solution. “This committee should include a clinical manager, QA clinician, a finance and a billing representative at a minimum, and they should be communicating with the governing body to ensure a smooth transition,” she recommends.

4. Consider big case management changes. Under PDGM, “agencies need to learn to actually ‘manage’ patient care in real time for each week on service,” Warmack stresses. “Monitor for missed visits, PRN visits, changes in supply needs, etc.”

Finance expert Pat Laff with Laff Associates in Hilton Head Island, South Carolina, recommends a case management model that puts one “primary clinician” in charge of the patient and responsible for managing her care. That patient gets “case conferenced” with a supervisor at least every 14 days.

What makes that system doable is that the primary clinician communicates with other members of the interdisciplinary team, then relays that info to the supervisor in a one-on-one conference via phone, Laff says. That eliminates time- and resource-wasting in-person meetings of entire IDT teams, where patient discussions are rushed or even skipped altogether, he maintains.

Bottom line: Under PDGM, “we can’t give field staff autonomy to provide patient care as they see fit and not analyze the care until the end of the episode,” Warmack contends.

An added benefit of this case management model will be increased quality scores, Laff says.

A supervisor should be “monitoring patient-specific utilization with meaningful goals and outcomes,” Griffin exhorts.

5. Address billing changes. Billing will change significantly under PDGM, thanks to the new 30-day episode. “Agencies that do not have a good control over their current billing practices will find themselves getting bogged down, since they will now have two RAPs and two claims for every 60-day episode,” Magrady notes. “This could significantly affect cash flow, which may also be impacted by the shift in payment methodology.”

Can your current billing staff “handle a double workload beginning Jan. 1, 2020?” Warmack asks. If not, you’ll need to staff up.

Plus: “Make sure your billing processes are solid. If your electronic medical record system has productivity reports, look at how many days from the assessment date to submission of the RAP bill and how many days from end of episode to final claim,” Magrady urges. “If your RAPs are taking longer than seven days to go out and your final claims more than 10 days, investigate to identify and address issues now.”

6. Scrutinize orders process. In your billing analysis, you might find slowdowns due to late paperwork from referring physicians. Agencies must ensure “timely and accurate completion of paperwork,” Griffin emphasizes. (That goes for paperwork from internal staff as well.)

“Review order processing for any systemic issues that result in hold-ups to receiving signed orders,” Osentoski recommends.

7. Diversify referral sources. Days of being a “niche” provider may be gone once PDGM takes effect, Markette predicts.

Agencies should “look to diversify their referral sources to ensure that they have a good mix of patient characteristics,” Magrady advises.

8. Start working on OASIS accuracy. A big part of your PDGM payment will rely on OASIS functional item scoring. (Reminder: PDGM cuts clinical domain OASIS item scores as a case mix factor altogether, replacing them with enhanced diagnosis coding factors instead.)

You need to make sure your staff are answer- ing the eight OASIS functional items accurately, Magrady urges. They are M1800: Grooming; M1810: Current ability to dress upper body safely; M1820: Current ability to dress lower body safely; M1830: Bathing; M1840: Toilet Transferring; M1850: Transferring; M1860: Ambulation/Locomotion; and M1033: Risk for hospitalization. M1800 and M1033 are both new to the case mix system under PDGM.

Do this: “Evaluate staff completing OASIS assessments for their accuracy,” Osentoski says. “This includes therapists who complete start of episode OASIS assessments.”

9. Renegotiate therapy contracts. Many HHAs are doing some serious analysis and reworking of their therapy policies and procedures, given that PDGM cuts therapy visit utilization as a case mix factor entirely.

In light of that change, “begin to renegotiate contracts with contract therapists,” Warmack advises. “For example, try to decrease the cost of a visit and negotiate a different rate between a physical therapist versus a PT assistant, an occupational therapist versus a certified OT assistant,” etc.

10. Prepare for a cash shortfall. “Work with a lender now to secure a line of credit to cover the first three months of 2020,” Warmack urges.

11. Line up cost-cutting steps. While PDGM is supposed to be budget neutral, CMS has proposed making a preemptive 6.42 percent “adjustment” to reduce rates in anticipation of HHA behavioral changes. And on an individual level, many agencies will see cuts to their pay based on the major case mix changes in the model, Markette notes. Now is the time to generate cost-cutting ideas, and begin implementing them gradually, he stresses.

For example: HHAs may want to explore using more therapy and nursing assistants, Osentoski suggests.

Increased use of remote monitoring may be another cost-cutting strategy, Markette offers.

Whatever your cost-cutting ideas are, make sure they are in place by January, so you can realize their savings when PDGM — and its cuts — hit.

12. Analyze your pay structure. If you’re still paying staff per visit, PDGM’s onset is a great time to change that. Under the new model, efficiency and quality are top priorities, Laff notes.

HHAs should consider trying to provide their staff with financial incentives that align with their own, Markette says. And that’s likely to mean eliminating incentives for clinicians to provide unnecessary visits.

13. Check assessment staff capacity. Just as the workload will be increasing for your billers under PDGM, it is also likely to increase for your assessment staff, thanks to a predicted increase for SOC and Significant Change in Condition assessments.

“Does the agency RN staffing have the capability to handle the extra workload?” Warmack asks. Plus, “nursing staff will need re-training on recognizing the events or patient changes that require a SCIC. Agencies have been lax in conducting these assessments despite regulations telling them to do so.”

14. Accommodate RCD. HHAs in Illinois are beginning the pre-claim review Review Choice Demonstration June 1. But the other four demo states may be launching RCD by early next year.

“Agencies that are also subject to the Review Choice Demonstration will need to make sure their planning includes more billing periods and takes into account the increased administrative burden that will entail,” Magrady points out.