Prospective Payment System:
LUPAs, REFINEMENT CRITICISMS
Published on Tue Jun 12, 2007
HHAs find a lot to like in the proposed changes, too.
Don't hold your breath waiting for major changes to the proposed prospective payment system revisions.
The Centers for Medicare & Medicaid Services has a tight timeline for issuing a final rule 90 days in advance of the target Jan. 1 implementation date for PPS changes, notes Bob Wardwell with the Visiting Nurse Associations of America.
The shortness of time, with a final rule expected by Oct. 1 to meet the three-month timeframe, "argues against there being many changes," says Wardwell, a former top CMS official who headed up PPS' original design. That especially goes for major structural changes.
CMS may be more likely to make easy substitutions or deletions, Wardwell predicts, such as reducing or eliminating the cut for case mix creep.
PPS clock ticks: That tight timeframe was a favorite topic for many parties commenting on the rule. Home Care Association of Colorado members "are extremely concerned with the administrative burden of the rapid implementation schedule of such complex changes" to PPS, the trade group says in its comment letter on the proposed rule.
The proposed revisions will require major software and OASIS changes from agencies and vendors, the association notes. It's not just HHAs' ability to adapt at issue, says CAHC. Fiscal intermediaries have proven unable to keep up with past changes of this magnitude. "This very tight implementation schedule raises great concern about the potential for claims processing delays and errors," the association warns.
Fallback: The group urges CMS to put a contingency plan in place to ensure providers' cash flow if reimbursement system delays arise due to the changes.
Industry representatives are also concerned with the transition's cost. "Forms and software need to be changed, staff need to be reeducated, and changes in process may need to occur," the Home Care Alliance of Massachusetts tells CMS in its comment letter. "These all cost agencies a great deal of time and resources which equate to money."
Other top comments include: • Positives. It wasn't all criticism for the PPS changes. Industry reps lauded CMS for numerous revisions, including adding a low utilization payment adjustment (LUPA) add-on; eliminating M0175 and significant changes in condition (SCICs) from PPS calculations; auto-adjusting therapy visit levels for final claims; making PPS more sensitive to patient condition; basing therapy payment on three tiers with individual visit smoothing payments; expanding the diagnoses included in case mix; adding a supplies case mix system; and implementing higher payment for later episodes. • LUPAs. While trade associations praised CMS for the $92.63 LUPA add-on, they also contended that it wasn't enough to pay for the significant cost of furnishing LUPAs. Medicare cost report data for 2001 to 2004 shows that LUPA payment rates are significantly [...]
