Home Health & Hospice Week

Warning: Turning utilization on a dime is a major red flag.

You may be contemplating some big changes as PDGM nears, but make sure you aren’t inviting fraud and abuse scrutiny.

The Patient-Driven Groupings Model will make some of the most sweeping changes to Medicare home health payment since the Prospective Payment System began nearly 20 years ago. Chief among those revisions is eliminating therapy from the PPS case mix system altogether, after almost two decades of adding a big reimbursement bump for the service.

Naturally, home health agencies are contem­plating big changes for their therapy policies and procedures. “A huge culture change for my clients is the decrease in utilization of therapy,” reports consultant Pam Warmack with Clinic Connections in Ruston, Louisiana. “Physicians and patients are spoiled in receiving therapy repeatedly. It is going to take quite a bit of time to redirect this way of thinking to the design of PDGM.”

It’s not just the amount of therapy that’s at stake. Providers also will be reexamining their therapy visit scheduling, expects finance expert Pat Laff with Laff Associates in Hilton Head Island, South Carolina.

Before: Some HHAs, particularly those specializing in post-joint-replacement patients, have been frontloading therapy visits to make sure they get in enough visits to exceed the Low Utilization Payment Adjustment threshold before patients are no longer homebound and go to outpatient therapy, Laff observes.

After: Now those agencies have to worry about having such episodes end up as only one 30-day billing period under PDGM, thus cutting their reimbursement in half. Accordingly, such agencies may try to change their visit scheduling to occupy two 30-day episodes.

Whatever changes you are considering, be aware that the Centers for Medicare & Medicaid Services and its contractors will be watching like hawks for inappropriate utilization changes, warns attorney Robert Markette, Jr. with Hall Render in Indianapolis. CMS emphasizes the oversight in the 2020 final payment rule.

“We will monitor utilization trends after implementation of the PDGM in CY 2020 to identify any aberrant behavior or significant changes in practice patterns that may signal potential program integrity concerns and investigate such occurrences accordingly,” CMS pledges in the rule.

In another rule section, CMS promises it “will closely monitor utilization patterns, beneficiary impact and provider behavior to see if any refinements to the PDGM are warranted, or if any concerns are identified that may signal the need for appropriate program integrity measures.”

And the agency vows to “closely monitor patterns related to utilization, including changes in the composition of patients receiving the home health benefit and the types and amounts of services they are receiving.”

Those are just a few of the mentions the rule makes of monitoring HHA utilization. CMS’s repeated emphasis on the topic should put agencies on alert that the agency means business when it comes to drastic shifts in utilization, Markette tells Eli.

For example: “If you wake up on Jan. 1 and stop providing therapy for all patients, that’s a red flag,” Markette says. Even a less radical shift, such as switching most patients from 13 therapy visits to six therapy visits as soon as PDGM starts, will make CMS “unhappy,” Markette warns.

Investigations, Program Integrity Measures Wait For Utilization Changers

CMS hasn’t been too specific about how it will handle such cases, Markette acknowledges. The final rule vaguely alludes to investigations and program integrity measures.

But HHAs shouldn’t be surprised to see providers with drastic utilization shifts undergo Targeted Probe & Educate review, Zone Program Integrity Contractor review, or other types of enhanced scrutiny, experts predict.

On the other hand: Clearly, many HHAs furnishing high levels of therapy to most of their patients will not be able to afford to continue to do so under PDGM’s reimbursement structure. “No money, no mission,” Markette points out. Agencies that continue their current heavy therapy provision will end up closing their doors under PDGM.

“We will not be able to provide the volume of therapy that we have in the past,” Warmack says. This will be difficult for some referring physicians to accept, because “when they send a referral that says, ‘PT, OT, SLP to evaluate and treat,’ [they believe] the agency will automatically admit and provide all this therapy.” Some significant education for referral sources is therefore in order as well, she recommends.

HHAs that need to change their therapy procedures likely will consider a number of steps, Markette says, including diversifying patient base, using therapy aides instead of therapists, and making therapy visits more efficient.

While making such changes should be expected, HHAs that change utilization overnight on Jan. 1 will be the ones that catch reviewers’ eye, Markette cautions. A gradual decline over time will be more defensible.

When making changes, agencies should be sure to keep their focus on care quality and excellent documentation, Markette counsels. Being able to back up utilization changes with good quality data will be helpful.

Consider modeling your utilization on high-quality providers, Markette adds. A slow decline of therapy visits over time due to a focus on quality is justifiable.

And make sure communication about changes is clear. “Collaboration of the quality assurance and compliance team members with the direct patient care clinical leaders to ensure that quality is never compromised” is key, advises consulting firm McBee Associates in its blog.

Note: The final rule is at www.govinfo.gov/content/pkg/FR-2018-11-13/pdf/2018-24145.pdf.