Reimbursement:
FEDS THROW UP HURDLES TO BLOCK GAMING IN PPS REVISIONS
Published on Tue Apr 17, 2007
Resulting complexity leaves providers scratching their heads over impact.
Toss out all your preconceived notions about which patients are profitable and which aren't under Medicare's prospective payment system.
The PPS changes proposed by the Centers for Medicare & Medicaid Services are very complicated, experts note.
As a result, there are no clear-cut winners and losers if the revisions take effect as proposed, judges Mark Sharp with BKD in Springfield, MO.
Then: That's unlike when CMS first proposed PPS in 1999, industry veterans recall. Then some financial benefits were pretty clear from the outset--for example, patients needing 10 or more therapy visits would be profitable while those with extensive visit and supplies needs, such as wound care patients, wouldn't.
Now: Home health agencies still aren't likely to lose out on patients needing therapy, Sharp predicts. The PPS revisions call for a three-tier therapy threshold at 6, 14 and 20 visits. Reimbursement for patients needing from 10 to 13 visits will generally be lower under the new PPS rules than the current ones. Conversely, patients needing six to nine visits will probably garner higher reimbursement than under current PPS, he forecasts.
And CMS may reimburse for wound care patients more adequately. The agency has included the M0 questions on wounds in the new nonroutine supplies (NRS) payments (see Eli's HCW, Vol. XVI, No. 17), points out consultant Lynda Laff with Laff Associates in Hilton Head, SC. And CMS has reweight-ed certain wound-related case mix items.
The new therapy reimbursement continuum is just one way CMS is trying to make its home care system less easily manipulated by providers, experts point out. "I have been getting multiple questions about [therapy] 'strategies,'" notes physical therapist and consultant Cindy Krafft with UHSA in Atlanta. "There are NONE. Trying to make one will further raise concerns about gaming," Krafft warns.
Safeguard: Wheth-er it's intentional or not, the drastically increased complexity of PPS calculations will make the system more gaming-proof as well.
Under the proposal, instead of just assigning points to OASIS case-mix items and adding them up, CMS has a tricky "four-equation" model. It bases payment on case-mix item points in conjunction with clinical conditions represented by diagnoses. The OASIS items "interrelate much more," Sharp stresses.
Episode number and the previously mentioned therapy continuum also affect payment significantly. Impact Is Agency-Specific Sharp hopes that the new complexity will result in a payment system that is more sensitive to patient acuity and reimburses agencies more accurately for the care needed.
But for now, the intricacies are making it difficult for HHAs to judge how the PPS changes would affect their bottom lines.
HHAs "have to get into it episode by episode," tabulate the new HHRGs, run them through the PPS grouper and judge how their current payments would [...]
