Home Health & Hospice Week

Pointer: Document your efforts to persuade patients to allow visits.

If home health agencies aren’t careful, creeping LUPA rates can make the difference between sinking or swimming under PDGM and COVID-19. Consider this expert advice to cope with Low Utilization Payment Adjustments under the new Patient-Driven Groupings Model, while also facing down the worst pandemic in a century:

1. Know your new thresholds. Unlike under the previous payment system’s five-visit starting point for all LUPAs, PDGM has varying thresholds for different case mix groups. The points at which LUPA payments stop and full episode payments kick in can be as low as three visits for some case mix categories, and as high as seven for others (setting the threshold at two to six visits).

“Really know the threshold,” urges consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama.

“Care planners will have to understand what the case mix will be,” points out Sharon Harder of consulting firm C3Advisors. That may seem daunting, “but it should be doable,” Harder says.

Resource: Download the Excel spreadsheet with the case mix categories and their LUPA thresholds at www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center under the CMS-1711-FC entry.

2. Gear care to avoid unnecessary LUPAs. “Do your best to try to meet the threshold,” Griffin advises. You should never expect to have no LUPAs, experts note — some situations, such as patients dying, are unavoidable. But often LUPAs happen because of sloppy care planning, missed visits, miscommunications, or other preventable errors.

Under COVID-19, agencies should “tailor visit frequencies so that they do, in fact, meet the patient’s needs without exceeding the number of in-person visits that are really needed,” Harder counsels. “Sort of like the ‘Goldilocks’ approach — just right, not too few visits and not too many,” she says.

“Frequencies should be planned up to the LUPA threshold and maybe one beyond for good measure, just in case we have a missed visit,” Harder further advises. Again, that will mean the care planners must know each patient’s care mix and LUPA threshold.

3. Balance telehealth. The Centers for Medicare & Medicaid Services has given HHAs flexibility to furnish services via telehealth, as long as the telehealth visits are in the plan of care and they don’t substitute for physician-ordered in-person visits (see Eli’s HCW, Vol. XXIX, No. 12-13).

Bad side: But those telehealth visits don’t count toward the LUPA threshold, even though CMS is reimbursing other providers such as hospitals and physicians for telehealth visits in the home.

CMS’ failure to count telehealth visits toward LUPA thresholds means agencies must carefully balance in-person and telehealth visits, keeping the patient’s care needs, the HHA’s financial viability, and regulatory requirements in mind.

“Use the structure you have in place (e.g. case conferences, driveway calls, etc.) to coordinate utilization of discipline visits and ‘telehealth touch points’ for the most effective plan of care,” recommends Karen Vance with BKD in Springfield, Missouri.

“Clinical teams should work to intersperse remote encounters between their in-person visits with specific interventions that will be addressed during those encounters,” Harder counsels. “For example, almost all patient teaching can be done remotely. In that way, we can save the in-person visits for those things that really require being directly in front of the patient and providing hands-on care.”

4. Monitor cases. Under PDGM and COVID-19, you may have to monitor visits more closely than you have in the past. “HHAs should monitor patient care levels throughout to ensure that a proper level of in-person visits is provided,” advises National Association for Home Care & Hospice President William Dombi.

“Closely monitor scheduling issues and missed visits,” urges consultant Sherri Parson with Quality in Real Time in Floral Park, New York.

5. Target high-risk episodes. If closely monitoring all cases proves difficult, focus on those that are most likely to run into LUPA trouble.

“Using data sources/analytics, understand the LUPA threshold patterns for your most common clinical groupings,” Vance suggests.

“Identify the diagnoses that may have high LUPA thresholds,” Parson recommends.

6. Take quick action. When visits are missed, you must recover quickly. “Clinical management needs to have strict oversight on all missed visits, and try to reschedule as soon as possible,” Griffin urges.

When missed visits are due to adminis­trative snafus like scheduling conflicts, “make sure you tighten up practices around those types of scenarios,” Parson stresses.

7. Ramp up education. You’ll need to spend considerable effort teaching both your patients and your own staff (see story, p. 145).

8. Consider discharges. “Remember, the HHA Conditions of Participation require agencies to get to the root cause of a patient’s refusal of care and to attempt to persuade them to accept the care, prior to discharging the patient for not cooperating,” reviews attorney Robert Markette Jr. with Hall Render in Indianapolis.

“There may be cases where a patient’s refusal to accept all ordered visits not only would create a LUPA, but would be an inadequate level of care to meet that patient’s needs,” Dombi cautions. “Patients should be so counseled and HHAs may need to consider rejecting such patients for admission.”

But turning down admission is often easier than discharging. “I am not a fan of discharging patients who are refusing care due to fear of COVID-19,” Markette says. “But it is not clear what CMS will do if we keep patients admitted to whom we cannot provide care.”

In those tough cases, “show CMS you did everything you could do to encourage the patient to cooperate with the provision of care, including accepting visits from the agency,” Markette advises.

9. Identify offsets. For now, as unavoidable LUPAs eat at your bottom line, you’ll need to come up with other ways to cover your expenses. “HHAs should look at what cost reductions they can make to offset the revenue losses,” Dombi suggests.

10. Keep an eye on the future. The LUPA going may get less tough as time passes, experts predict. Hopefully, “the LUPA increases will be short term rather than permanent,” Dombi tells Eli.

And CMS should take into account new utilization trends under PDGM when calculating future LUPA thresholds, Parson points out. “Next year the thresholds should be lower based on the industry’s lower visit utilization with care delivery this year,” she forecasts.

“As time goes on, some of the reluctance to entertain visits will recede,” Harder also expects.

On the other hand: “It appears that a significant portion of Americans will not find the lifting of lockdowns sufficient excuse to go back out — or to let HHA staff back into their home,” Markette observes. “HHAs will likely need to work to address LUPAs due to COVID-19 during the period of time after the PHE ends, because patients will almost certainly not be ready to just welcome HHAs back into their homes right away,” he says.

CMS could help. “Maybe in months or years to come, a compromise of ‘telehealth’ can be reached,” hopes Pam Warmack with Clinic Connections.“Technology is the wave of the future, and CMS is holding home health in the stone ages.”