Home Health & Hospice Week

Don’t let paradigm-shifting payment reform put you at risk next year.

A year from now, you’ll be a few weeks into a radically revised payment system. To survive and thrive under the Patient-Driven Groupings Model, you need to start your preparations immediately, experts urge.

“2020 will be here faster than we know it,” warns Rhonda Perrin Oakes, a regulatory analyst with electronic health record vendor Netsmart. Home health agencies should prepare now for the changes coming Jan. 1, Perrin Oakes says on Netsmart’s Carethreads blog.

“We have one year, but I just think that year is going to fly by when I think about the complexity of the rule,” said Gina Mazza with Fazzi Associates in a Nov. 29 webinar on PDGM readiness. That’s especially true because “there’s very little … untouched by PDGM,” Mazza said.

HHAs hopefully are starting to try to figure out PDGM readiness now, says Julianne Haydel with Haydel Consulting Services and The Coders in Baton Rouge, Louisiana. And they should “begin faux implementation in the second half of 2019,” Haydel urges.

“Organizations that take steps today will find success in PDGM tomorrow,” Perrin Oakes maintains.

Don’t underestimate just how much work it will be to switch to PDGM, Mazza added. It will require “lots of strategic thought and planning,” she emphasized, comparing it to the switchover from fee-for-service billing to PPS billing in 2000.

“This is a major change to PPS,” Haydel underscores.

“PDGM is going to be a big change for HHAs,” stresses Sandy McCleve with Advantage Healthcare Consulting Cost & Reimbursement in North Salt Lake, Utah. “It is extremely important for these providers to understand the new rules; otherwise it will most certainly lead to a negative financial impact on their agency.”

Consider this advice from the experts to make sure you are prepared when PDGM hits in less than a year:

1. Study up. Now that the Centers for Medicare & Medicaid Services has finalized PDGM in the 2019 HH Prospective Payment System final rule, “agencies should seek to gather information on all the changes that will be coming,” advises consultant Joe Osentoski with Quality In Real Time in Troy, Michigan. Sources of information include the final rule and an upcoming PDGM call from CMS (see box, p. 11).

Major components of the rule are the switch to a 30-day billing period, eliminating therapy from case mix calculations, including source of admission as a case mix factor, and pay-rate reductions for behavioral adjustments (see more details in Eli’s HCW, Vol. XXVII, No. 39-40).

2. Run your numbers. Along with the final rule, CMS has provided PDGM grouper and agency level impact tools. Use those to model the impact on your agency, Mazza recommended.

Using the model will allow agencies to “see how they would fare in a PDGM model of billing their current clients,” Osentoski tells Eli.

“You need to understand where you are right now” on all the important measures, ranging from coding to Low Utilization Payment Adjustments, Mazza urged.

Watch out: You should also factor in elements that won’t show up in the model. For example, take a close look at your length of service in relation to the new 30-day billing period, Haydel says. Many episodes that would count as two 30-day periods in the model may actually get shortened to just one, or one with a LUPA. “For years, we have been preaching that shorter episodes are better,” Haydel notes. “But a 45-day episode could easily turn into a LUPA.”

3. Form a PDGM implementation committee. You need a group of “horizontally and vertically” integrated staffers to “champion PDGM” in your agency, Mazza counseled. This “should not be a management function,” but rather have representatives from all your agency’s “core competencies,” she said.

4. Make your PDGM plan. Using the analysis you have gathered, you need to “break down the needs into a plan that will have an accomplishment date of December 2019,” Osentoski recommends. Mazza emphasized the need for a “strategic approach” in formulating your PDGM action plan.

5. Focus on diagnosis coding. Every agency’s plan will look different, based on its individual needs. But providers can count on diagnosis coding being a big feature, thanks to PDGM’s focus on the area. In the final rule, “CMS affirms the importance of ‘precise coding’ in the new model, so assuring that your coding resources are up to the task will be extremely important,” Osentoski stresses.

Pinpoint: “Collecting complete health histories with a complete recording of comorbidities” will be a must under PDGM, thanks to the payment adjustment for comorbidities, Perrin Oakes notes.

6. Emphasize OASIS. Likewise, accurate OASIS coding will also be paramount under PDGM. “Developing a strong understanding of OASIS requirements by clinicians and coders” will be key, Perrin Oakes emphasizes.

Why? Accurate OASIS collection lays “the foundation for capture of acuity, revenue and [lays] the pathway to effective care planning,” according to an earlier PDGM webinar by Mazza. It also determines risk stratification.

7. Target effective care coordination and discharge planning. Most HHAs will need to focus on these areas in their PDGM transition, experts predict. Providers will need to be “collaborating between cross-functional teams to provide coordinated care,” Perrin Oakes advises.

Are you “using accurate acuity capture to drive and execute evidence-based, interdisciplinary best practice care plans?” Mazza asked.

8. Secure buy-in. Drafting a comprehensive PDGM implementation plan isn’t enough. You need to get your staff on board, Mazza emphasized in the webinar.

That means rolling out early education to leaders and employees, who need to understand why they are doing things. Your agency-wide committee should be able to help in this area.

9. Achieve optimal productivity. You may want to borrow from Encompass Health’s PDGM prep list. The 30-state chain includes “ensure productivity levels are realized for full-time staff” on its to-do list for 2019, according to its Jan. 8 presentation at the J.P. Morgan Healthcare Conference.

Plus: Using technology to “drive incremental efficiencies” also made Encompass’ PDGM preparation list.

10. Stay tuned. 2019 “may see further refinement of the regulation before it goes into effect,” Perrin Oakes cautioned. The industry is lobbying hard for certain changes, such as elimination of the preemptive behavioral assumption reimbursement cut. Keep on top of new information CMS issues.