Home Health & Hospice Week

Pay won’t come close to covering cost.

Under the Patient-Driven Groupings Model, a 30-day billing period that falls into the Low Utilization Payment Adjustment range will get paid at the much lower per visit payment rate. While home health agencies will want to avoid any unnecessary LUPAs, some will be inevitable.

At least LUPA billing periods also will continue to qualify for an add-on payment when the episode is the first or only episode in a sequence of adjacent episodes. “LUPA add-on payments are made because the national per-visit payment rates do not adequately account for the front-loading of costs for the first LUPA episode of care,” the Centers for Medicare & Medicaid Services explains in the 2019 HH PPS final rule. “The average visit lengths in these initial LUPAs are 16 to 18 percent higher than the average visit lengths in initial non-LUPA episodes.”

CMS will propose the exact rates for PDGM in its proposed rule expected out in July and finalized in late fall. But you can get an idea of what they’ll pay by looking at this year’s rates (see box, below).

For the add-on payment for initial episodes, CMS is keeping its current calculation: “Multiply the per-visit payment amount for the first skilled nursing, physical therapy, or speech-language pathology visit in LUPA periods … by the appropriate add-on factor (1.8451 for SN, 1.6700 for PT, and 1.6266 for SLP) to determine the LUPA add-on payment amount for 30-day periods of care under the PDGM,” CMS notes in the rule.

Using 2019 rates, add-ons would be $270.31 for SN, $267.43 for PT, and $283.13 for SLP. But remember — those add-ons won’t apply to a second 30-day billing period.