Home Health & Hospice Week

Wake up to revenue changes before it’s too late.

If you feel like you’re facing a plethora of problems under the Patient-Driven Groupings Model that took effect Jan. 1, you’re not alone.

Six weeks into the drastic new payment system, lots of trouble areas are plaguing home health agencies, providers and industry experts from around the nation report. Take a look at the top problems HHAs are encountering under PDGM:

1. Therapy utilization. PDGM’s case mix system eliminates therapy utilization as a payment factor, and that is throwing many agencies for a loop. Problems range from providing too much therapy to not enough — and the feds are taking notice, not to mention the mainstream press (see story, p. 44).

2. Cash flow. Cash flow is one of “the biggest problems and challenges” under PDGM, judges Tom Boyd with Simione Healthcare Consultants in Rohnert Park, California.

“Low RAP payments on PDGM payment periods have been a real shock in many organi­zations,” relates reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. Under PDGM, RAP payments dropped from 50 or 60 percent of a 60-day episode’s payment to 20 percent of a 30-day episode’s payment. “I believe the impact of the low RAP payments will lessen as the months progress, but in January and this early into February, it has been an issue,” Little continues.

The cash flow crunch gets worse when agencies see delays in their final claim billing. “The biggest issue I have seen is that some agencies don’t have the efficiency of getting the OASIS complete, coded, and to the biller within 7 to 10 days of [Start of Care], so that it is billed and done and revenue received before the next 30-day mark to bill,” reports Kyle Johnson, owner and director of coding operations with Home Health Coding Solutions in Brigham City, Utah. Some HHAs “have the biller piling up as they try to get all the SOCs billed as the 30-day mark hits.” Meanwhile, billing for the second 30-day period is stalled.

“I am shocked how many are only now trying to get loans and credit lines,” Boyd tells Eli. “We have been recommending that since at least last summer. The time to borrow money is when you don’t need it.”

Even if providers have enough resources to avoid a cash flow crisis due to billing delays, “just trying to figure how much payment [is] coming in when [is] posing a challenge,” adds Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan.

3. Documentation shortfalls. Contributing to the cash flow crunch is missing or delayed documentation to back up the claim.

For example: Providers are “having some difficulty getting orders back timely to allow for final billing and get that 80 percent payment at that time,” Osentoski relates.

And it’s not just physician orders causing problems. “The revenue cycle folks are just waking up to some of the extraneous things that they need to be tracking before final claims are dropped — like, determining that the OASIS was, in fact, successfully transmitted, that documentary evidence of the inpatient stay and dates is in the record to substantiate Occurrence Codes on the final claim, etc.,” says Sharon Harder, president of consulting firm C3Advisors in Wheaton, Illinois. (See more on admission source problems in story, p. 44.)

“We got fixated on the fact that PDGM re- quires more billing volume,” Harder tells Eli. “But there are lots more moving parts that agencies didn’t have before, and this is requiring some additional adjustment and work toward greater efficiency.”

“The agencies’ billing processes have changed and work has increased,” reports Julianne Haydel with Haydel Consulting Services and The Coders in Baton Rouge, Louisiana. “Since there is so much that needs to be done before dropping that first 30-day claim, agencies that do not tighten up their processes will soon find a reason to do so as the first billing cycle is underway,” Haydel warns.

4. Diagnosis coding. As expected, diagnosis coding is a huge source of difficulty under PDGM. Many coding problems boil down to pinning the referring physician down on the most appropriate primary diagnosis, but also involve identifying appropriate secondary diagnoses — and making sure there’s documentation for all of it.

Reminder: Under PDGM, the primary and secondary diagnoses play a major part in setting the case mix category and reimbursement level. And many frequently used codes are now “invalid” under PDGM and cause claims to return to agencies.

“We are … seeing new coding challenges, especially related to physician referrals where the patient might have a previously undiagnosed wound,” Harder says. “As the assessing clinician identifies the condition and the need for treatment, agencies are having to jump through some hoops to get these properly diagnosed so that treatment can be added to the Plan of Care interventions,” she notes.

And: “For many patients, the medical record documentation gathered over time has inconsistencies and/or gaps. These are causing a need for a structured query process, and queries have not been used in a major way in home health before,” Harder observes.

Reminder: When coders need more infor-mation from a physician to determine or support a diagnosis code, questioning them is known as a “query.” Providers often use a standard query form for the process.

“Many agencies did not institute query processes in 2019,” Harder says. “So, this becomes yet another job for the clinical team — especially when the coders are employed by outside organi­zations and not necessarily in a position to directly query the physician on the agency’s behalf.”

HHAs are also getting pushback from physi- cians on the issue. Physician practice “nurses … feel we are asking them for more diagnosis specifics,” reports a staffer at one Indiana HHA. “My challenge [is] trying to get them to understand why we need it now versus in the past,” she tells Eli.

HHAs that don’t have knowledgeable coders on the job — whether in-house or outsourced — also “are having a lot of issues with denials,” Johnson relates. And they are “not fully understanding the PDGM coding change and how the primary code affects the entire revenue stream — as well as codes that are no longer allowed primary.”

Another wrinkle: CMS has clarified that HHAs may change a patient’s diagnosis for a second 30-day episode without completing a new OASIS (see Eli’s HCW, Vol. XXVIII, No. 18). But agencies are having trouble with operationalizing that change, often due to software, says consultant J’non Griffin owner of Home Health Solutions in Carbon Hill, Alabama. “There are little to no processes in place for this,” Griffin notes.

5. iQIES. PDGM has come with a host of trouble spots, but most of them were anticipated with plenty of advance warning. An exception is the problems with the Internet Quality Improvement and Evaluation System that also took effect Jan. 1.

CMS is still working to get the many iQIES kinks worked out (see Eli’s HCW, Vol. XXIX, No. 5), and the resulting delayed OASIS submissions are holding back end-of-episode claim submissions, experts point out.

6. Utilization management. Therapy isn’t the only service going through “rightsizing.” HHAs that are receiving less reimbursement under PDGM are struggling to find efficiencies wherever they can, and that includes figuring out how to achieve the same quality outcomes with fewer visits.

“Old habits die hard,” Harder says.

7. Scheduling and LUPAs. Often managing utilization goes hand-in-hand with avoiding Low Utilization Payment Adjustments, which are easier to trigger under PDGM with some billing periods having a LUPA threshold of up to six visits in 30 days.

“It is much easier to talk about utilization management and LUPA avoidance than it is to make it happen,” Harder surmises. “Many clinicians are not thinking about their visit frequencies in terms of how they fall into two 30-day periods within an episode, or how the payment period cutoff dates in the middle of a week could produce an unintended LUPA simply due to visit timing during a seven-day period,” she rues.

8. RCD. “Texas providers also have to deal with Review Choice Demonstration” starting in March, just as they are getting ramped up on PDGM, notes Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas.

Currently, many episodes are still “PPS carryovers,” Osentoski points out. But the PPS cash will be running out just as RCD hits in Texas.

And remember: Whether in Illinois, Ohio, or Texas, HHAs that are on RCD Option 2 with 100 percent post-payment review “will have to submit an ADR for every claim to receive payment — quite an administrative and logistics burden,” Osentoski notes.

As of Feb. 11, 8 percent of Texas agencies submitting their RCD selection had chosen Option 2, HHH Medicare Administrative Contractor Palmetto GBA notes on its website. That is despite the fact that experts generally recommend Option 1: 100 percent Pre-Claim Review.

But that figure doesn’t take into account the Texas providers that don’t submit their selections. CMS will automatically place them into Option 2 after the Feb. 13 selection deadline.

9. Managed care. Figuring out which payers need which information — and thus what you have to collect, compile, and submit — is confusing when some plans have adopted PDGM elements while others haven’t. That’s where many providers are at the moment, notes attorney Robert Markette Jr. with Hall Render in Indianapolis.

Note: For tips on tackling these trouble spots, see future issues of Eli’s Home Care Week.