Home Health & Hospice Week

Commenters want the behavioral cut gone.

In a few short weeks or even days, home health agencies will know what their Medicare reimbursement rates for next year will be.

As it does annually, the Centers for Medicare & Medicaid Services is expected to release the 2021 home health payment final rule in late October or early November.

HHAs are hopeful that CMS will listen to the scores of comment letters on the proposed rule urging better reimbursement as agencies continue to tackle the pandemic. The vast majority of the 166 comment letters advocate for improved payment on a number of fronts.

However, a relatively light response may affect just how persuasive public comments are this year. This year’s 166 letters compares to 587 last year, when the Patient-Driven Groupings Model was taking effect. But it’s more than in some years — there were 364 letters in 2014, 120 letters in 2015, 89 letters in 2016, 1,350 letters in 2017 (when PDGM’s predecessor, HHGM, was introduced), and 1,345 letters in 2018 (when PDGM was proposed).

Most comment letters this year took aim at the reimbursement cut CMS made for behavioral changes it assumed agencies would make in response to PDGM. Medicare officials believed agencies would change coding practices and gear utilization toward LUPA thresholds. CMS at first proposed an 8.01 percent cut for the assumptions, then lowered it to 4.36 percent in the final rule for 2020.

“We are not seeing the types of changes in our care that are modeled into the assumptions and believe that there are resources being taken away from our ability to hire, support, and protect our workforce at this critical time based on faulty assumptions,” Steven Landers, CEO of the VNA Health Group in Holmdel New Jersey, says in his company's comment letter on the proposed rule. “This unwarranted and unlegislated cut to home health care will ultimately hurt the quality and availability of care for Medicare beneficiaries.”

The cuts are based on “the alleged and spurious CMS position that the industry is continually looking for and finding ways to defraud/abuse the Medicare Program,” blasts accountant John Reisinger with Innovative Financial Solutions for Home Health in Tampa Florida. “If this was as widespread as alleged, CMS, the OIG and FBI should be closing multiple home health agencies daily; but that does not happen,” Reisinger stresses.

“There is no reasonable statistical justification for this cut,” Home Care Association of New York State’s Patrick Conole says in the trade group’s comment letter. “We find the methodology, assumptions, analytic documentation, and underlying data supporting these behavioral assumptions troubling, especially considering CMS did not apply the same type of adjustment to the PDGM methodology for the nursing home industry,” Conole charges.

“The behavioral adjustment for the clinical group coding and the LUPA avoidance are unrealistically high,” Conole adds.

National chain LHC Group Inc. points to a recent study by health economics consulting firm Dobson DaVanzo & Associates that shows PDGM payments are up to 22 percent under budget-neutral levels (see HCW by AAPC, Vol. XXIX, No. 33). “Based on this work, it is perfectly clear that the LUPA adjustment is no longer warranted. We believe there is a serious lack of budget neutrality between aggregate CY 2020 and CY 2019 home health payments,” LHC says in its letter. “To achieve and maintain budget neutrality CMS should fully reverse the 4.36 percent behavior adjustments imposed for the remainder of CY 2020 and all of CY 2021.”

The behavioral assumptions were off for January and February, according to the Dobson study. But when COVID-19 hit in March, it exacerbated the problem. “Clearly, the actuarial models CMS formulated for the behavioral assumptions could not have possibly accounted for the numerous abrupt, negative, and unprecedented impacts of this pandemic on America’s overall economy and our healthcare system that began occurring during the early portions of 2020, many of which remain presently and will persist into 2021 and beyond,” says chain Encompass Health in its comment letter. “Permitting the perpetuation of assumptions about home health care providers’ behavioral responses to PDGM that do not appear to be occurring at predicted levels poses risks for the provision of high quality, effective home health care for Medicare beneficiaries, and erodes payment accuracy,” Encompass criticizes.

“The COVID-19 pandemic has severely disrupted home health service and utilization patterns, making a 4.36 percent negative adjustment almost arbitrary in its application” Visiting Nurse Service of New York CEO Marki Flannery tells CMS in the agency’s comment letter. “We may see an increase in Low Utilization Payment Adjustments (LUPAs) because of the use of virtual visits to preserve staff and PPE and prevent the spread of COVID-19,” Flannery points out.

Due to COVID-19 derailing any meaningful data reconciliation, health system CHRISTUS Health urges CMS to “remove the examination of the behavioral changes requirement altogether, given existing and future uncertainty and the implications it has on coding and/or LUPAs,” CHRISTUS VP Michael Talley says in the system’s comment letter.

Corrections can’t wait: In the proposed rule, CMS said it would wait until the next rulemaking cycle to make any changes based on data under PDGM. “Waiting to correct for these overestimations in 2022 or later could potentially require a larger adjustment(s) than what would otherwise be required if a correction is pursued earlier,” Encompass points out.

And many agencies can’t afford to be underpaid for another year or more. Medicare will damage an essential cost-saving component in the care spectrum if it waits. “HHAs are becoming increasingly necessary to decrease the cost of healthcare for CMS patients by providing care in the home, eliminating the burden of high overhead costs of nursing homes, skilled nursing facilities, and assisted living facilities,” argues Anne-Marie Fontenot in her comment letter.

The pandemic has caused an increased demand for home care, while agencies are financially penalized by no direct reimbursement for telehealth visits, adds physical therapist Paul Breyen in Prior Lake, Minnesota, in his comment letter. “I strongly encourage CMS implement a larger increase. Patients are safest at home during a pandemic, and home health providers risk their own safety to ensure that these patients continue to receive quality care with minimum exposure. HHAs should be adequately reimbursed,” says Breyer and a number of other therapists and therapist students who submitted comments.

Note: The proposed 2021 HH rule is at www.govinfo.gov/content/pkg/FR-2020-06-30/pdf/2020-13792.pdf.