Advocate and Engage on PDGM

There are many ways that home health agencies will need to prepare their agencies for the radical changes coming from PDGM in January 2020. The Alliance is here to help.

Last month, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule for 2019 home health payment rates and policy changes, which includes significant provisions that will impact your organization, staff, and the patients you serve.

Between now and when the Patient Driven Grouping Model (PDGM) goes into effect on January 1, 2020, there are multiple ways that home health agencies will need to prepare their agencies for the radical change. (See Coding and Billing webinars coming in September, at the bottom of this page) At the same time, home care must take action to mitigate the impact of what PDGM will look like and how it will impact organizational viability.

Home care’s collective advocacy efforts have undeniably made a difference in the past, including putting a stop (at least in Massachusetts) to the Pre-Claim Review Demonstration and scrapping the Home Health Groupings Model thanks to more than 1,200 comments submitted to CMS last year. The more that CMS and lawmakers hear from home health professionals, the better our chances are at reducing the severe cuts that accompany PDGM in its proposed form.

As currently proposed, the 2020 rule will:

  • Reduce the Medicare base rate by 8.01% next year, which amounts to a $1.298 billion reduction in home health payments in 2020 alone. CMS proposes the reduction to account for anticipated changes in provider behavior that are unrelated to changes in patients served or services delivered that increase payments. This newly proposed “behavioral adjustment” reduction is up from the 6.42% reduction that CMS initially proposed, and the reduction would start before any actual behavioral changes occur.
  • Phasing out RAPS over 2020 with total elimination of RAPs in 2021. Next year, CMS proposed reducing RAPs from 60/50% to 20% for existing home health agencies (HHAs), while new agencies would get no RAP. CMS claims that RAPs create fraud risks.
  • Starting in 2021, a Notice of Admission (NOA) must be submitted Notice of Admission must be submitted within five days of the start of care. For every day late, CMS plans to reduce base-rate reimbursements for the unit of care.

The Solution: Pass S.433/H.R.2573

This month, Congress is in recess and back in the states, which presents a pivotal opportunity for home health industry professionals to engage with lawmakers about a key legislative priority – the Home Health Payment Innovation Act (S.433/H.R.2573).

This legislation prohibits CMS’s ability to adjust payment based on “behavioral assumptions” as opposed to observed evidence of behavioral changes, thus rescinding the proposed 8.01% adjustment.
Additionally, this important legislation would:

  1. Achieve full budget neutrality over the period of 2020-2029.
  2. Require behavioral adjustments based on real, actual changes in provider behavior in response to the new payment model.
  3. Permit a phase-in of rate adjustments (up or down) when an annual adjustment would be greater than 2 percent. However, the phase-in would operate to ensure full budget neutrality by 2029.

Email your Members of Congress

It’s not too late to get members of Congress informed and engaged on this important legislation. You can send an email directly from HCA’s member advocacy center.

At this point, Congressman Jim McGovern is the only member of the MA delegation signed on as a cosponsor. We must do better.

Fact Sheet: Senate 433 & HR 2573

Advocate in Person

Join home health industry advocates next month in Washington, D.C. for The Council of State Home Care Associations’ Third Annual Public Policy Summit and Advocacy Day!  On September 9, participate in a full-day summit featuring speakers including Hillary Loeffler, Director of the CMS’ Division of Home Health & Hospice.  On September 10, we be on Capitol Hill meeting with members of Congress to convey the critical need to pass S.433/H.R.2357.

Program details can be found here and registration information can be found at The Council’s website.

Submit Comments to CMS by September 9

Click here to submit comments to CMS in response to the 2020 proposed rule by 5:00 PM ET on Monday, September 9, 2019.

HCA and other industry organizations will provide more thorough comments on other problematic areas of the proposed rule. As previously stated, there is strength in numbers, so the more business-focused comments from providers – both large and small – are critical to giving CMS a full and clear picture of how devastating PDGM will be should it be implemented as proposed. Watch Update for draft comments.

Return to www.thinkhomecare.org.

HCA of MA Has Got You Covered for PDGM Education

HCA of MA is providing 4 unique opportunities at free or discounted rates to learn comprehensive elements of the new Medicare Patient-Driven Groupings Model (PDGM) being introduced this January.

HCA of MA is providing 4 unique opportunities at free or discounted rates to learn comprehensive elements of the new Medicare Patient-Driven Groupings Model (PDGM) being introduced this January.

PDGM: 4-Part Preparedness Series: August 6, 7, 13, & 14
Online Webinar Series

Is your agency prepared for the all the changes that will come with PDGM? This 4-part webinar series with Melinda Gaboury will give you the essentials your agency will need to prepare for PDGM. This series will cover coding changes, OASIS integrity, financial structure changes,LUPA’s, changes revenue cycles, and more!
• August 6th – PDGM Structure and Financial Changes
• August 7th – PDGM Coding & OASIS Integrity
• August 13th – PDGM Operational Decision Necessities
• August 14th – PDGM Revenue Cycle Changes
Instructor: Melinda Gabourey, Healthcare Provider Solutions

REGISTRATION
HCA Members: $379/Line for Full Series
HCA Potential Members: $599/Line for Full Series

All webinars are recorded

2020 Home Health Final Rule: September 11
Online Webinar

The 2020 Home Health Proposed Rule will be a seismic change in home health care. Learn from experts in the industry to help
understand the propsed rule and its impacts. Topics will include a review of Medicare’s new payment rates for home health, changes in use of PT assistants, and informed feedback to provide to CMS by the comments deadline of September 9, 2019, and more!

REGISTRATION
HCA Members: FREE
HCA Potential Members: $99/Line

PDGM Bootcamp: September 24, 9:00-4:00
Methuen, MA

Home Health Care Clinical Managers/Supervisors of Clinical Services, Quality Management staff and Clinical Educators will play a key role in the successful implementation of the new Medicare Patient Driven Groupings payment Model (PDGM). In this interactive session, attendees will learn the four key elements of the PDGM scoring system: admission source and timing, clinical groupings, functional levels and comorbidities. Managers will leave with specific techniques for obtaining accurate information to support coding, scoring and billing. All, while using the least resources to produce the best outcomes. Areas covered include: optimizing complex care, episode utilization and case management, interdisciplinary teamwork, care coordination and collaboration. The session will also describe key PDGM measures and monitoring techniques to optimize efficiency, achieve success and prevent pitfalls.

REGISTRATION
HCA Members: $159/Person
HCA Potential Members: $399/Person

PDGM Education by the National Association for Home Care
Online Webinar Series/ Videos

In a partnership with the National Association for Home Care, we are pleased to extend a special NAHC discount on several PDGM educational offerings all members of HCA of MA!

PDGM Video
If you’re familiar with PDGM but aren’t sure what the first steps are, this 5 ½ hour introductory course is for you. Leading industry experts will equip you with what you need to know to about the most significant change to impact home health in decades.

Webinar Series
If you want a deeper understanding of PDGM and how certain components will affect your business, this seven-part series is what you’ve been looking for. These webinars will focus on all parts of your agency, including risk factors, documentation review, clinical management and more. If you can’t attend the live webinar, don’t worry each of them will be recorded and available on- demand. You and your staff will have unlimited access.

Learn more on all education and register at:
www.thinkhomecare.org/Education

Members Flock to HCA’s Quality Improvement Meeting

Lots of member interest in HCA’s July QI meeting to discuss medical record audits and upcoming proposed rule changes.

With the sundry of regulation changes in the home health industry over the past few months, the July 24th Quality Improvement (QI) meeting had over 45 members participating in-person and by phone. The numerous medical record audits plaguing the industry dominated the meeting’s discussion.

Multiple agencies have received letters from C2C Innovation Solutions informing them that some claims under appeal have been selected for potential reopening as part of the Medicare Appeals Demonstration. The C2C auditors are conducting the analysis of claims previously adjudicated unfavorably by the Qualified Independent Contractor (QIC), that are currently pending at the Office of Medicare Hearings and Appeals (OMHA) and may be resolved favorably by the QIC.

Other audits that agencies are experiencing are new Targeted Probe and Educate (TPE) audits. These medical record requests are for 5-7 visits and lengths of stay greater than 90 days. No agency is in the third round of the Face-to Face TPE.

One agency reported at the meeting that they are facing three audits simultaneously; a hospice General Inpatient care (GIP) Targeted Probe from NGS, a home health PERM request for Face-to-Face (awaiting ALJ) and eight GIP Post Payment Review by Noridian.

During the meeting there was a lot of member engagement related the 2020 Proposed Rule; the proposal to require OASIS for all payors and the 8% behavioral adjustment. Agencies also discussed strategies for management with PDGM and the process for completing OASIS B-1 for January 1st episodes. PDGM will be a standing QI agenda item.

The HCA is planning to host a PDGM Networking Meeting to help our members with the transition to this new payment model. We are hoping to begin the meetings in September and have a guest speakers and consultants to assist with planning for this historic payment change. Stay tune for further details.

Don’t forget to check out our PDGM Bootcamp on September 24th!

New PDGM Bootcamp Announced!

HCA of MA has introduced a new full day training on PDGM for Clinical Managers/Supervisors and Quality Management Staff.
https://www.thinkhomecare.org/resource/resmgr/event_forms/PDGM_Bootcamp_Flyer_and_Reg.pdf

Home Health Care Clinical Managers/Supervisors of Clinical Services, Quality Management staff and Clinical Educators will play a key role in the successful implementation of the new Medicare Patient Driven Groupings payment Model (PDGM). In this interactive session, attendees will learn the four key elements of the PDGM scoring system: admission source and timing, clinical groupings, functional levels and comorbidities. Managers will leave with specific techniques for obtaining accurate information
to support coding, scoring and billing. All, while using the least resources to produce the best outcomes.

Areas covered include: optimizing complex care, episode utilization and case management, interdisciplinary teamwork, care coordination and collaboration. The session will also describe key PDGM measures and
monitoring techniques to optimize efficiency, achieve success and prevent pitfalls.

PROGRAM OBJECTIVES (At the completion of this session, participants will be able to….)

  • Describe key elements of Medicare’s PDGM payment model
  • Explain the impact of the new regulations on clinical operations and clinical managers
  • Identify key clinical operations changes that will be required for PDGM success
  • Create an initial action plan for successful PDGM implementation

ABOUT THE SPEAKER: Barbara Katz, RN, MSN is an experienced clinician, manager, trainer and health care consultant. Barbara has been a hospital registered nurse, an APRN in internal medicine, a site manager for a Kellogg Foundation self-care education grant, a training manager and a manager of clinical operations for a network of medical practices. She has been Vice President for Clinical Program Development in a large home health care agency where she founded a family caregiver support network.
Barbara provides training in leadership for value based payment, patient self-management support, family caregiver support, process improvement tools and techniques, population health strategies, the use of data
in daily work, communication, teamwork and motivational interviewing.

REGISTRATION:
Members: $159/Person
Non-Members: $399/Person

Or Download the Registration Form Here

“To get others to be involved: This conference was an eye opener to areas we need to improve upon and the tools provided will help in the process. This really brings it all together and a better understanding of PDGM.”

“This was excellent very informative. Made PDGM clear & understandable. Great tips to get started & to stay on task. Barb is a great presenter & her use of handouts was helpful.”

New PDGM Educational Material Now Available!

In a partnership with the National Association for Home Care, we are pleased to extend to you a special NAHC discount on several PDGM educational offerings. As a member of HCA of MA, you will receive the NAHC member rate* when you purchase any or all of the following:  1) the PDGM: Strategies for Success in 2020 and Beyond video;  2) the individual webinars;  3) seven-part Webinar Series;  or 4) the package,  which includes both the PDGM Video and the PDGM Webinar Series – at an unbeatable price!

Registration includes giving your entire team access to these materials. Each individual can access them separately or you can use them for a group education.  It’s  up to you!

Click on the links below to get started!

For one low price, you and your entire team will have access to these materials, access them separately or as a group, it’s up to you!

Click on the links below to get started!

PDGM Video

We’ve developed an intensive, in-depth, online training that will prepare you and your entire Medicare home health agency to transition smoothly and successfully to PDGM in 2020 and beyond. If you weren’t able to attend one of the 12 National Summits across the country, don’t worry. PDGM: Strategies for Success in 2020 and Beyond features the same top PDGM experts who educated thousands at our National Summits, and you can learn their insights without leaving your home or office. Even better, for one low price all of your staff can receive the training they need. Purchase the video

Webinar Series

These webinars will be recorded for access anytime and anywhere.  For descriptions and objectives, click here

PROMO CODE FOR INDIVIDUAL WEBINARS: PDGM-Ind-MA01

Date & Time Title Presenter
May 2, 2019
2:00-3:00 PM ET
PDGM Practical Overview Sue Payne REGISTER
May 9, 2019
2:00-3:00 PM ET
PDGM Operations Impact: Referral Source & Intake Maria Warren REGISTER
May 21, 2019
2:00-3:00 PM ET
PDGM Operations Impact: 30 Day Periods, LUPAs, Supplies Diane Link REGISTER
June 6, 2019
2:00-3:00 PM ET
PDGM: Coding / Documentation Review / Revenue Cycle Melinda Gaboury REGISTER
July 11, 2019
2:00-3:00 PM ET
PDGM: Interdisciplinary Considerations Karen Vance REGISTER
August 15, 2019
2:00-3:00 PM ET
PDGM: Electronic Medical Record Readiness Matt Garcia REGISTER
August 16, 2019
2:00-3:00 PM ET
Clinical Management of PDGM Risks Karen Vance REGISTER

Registration

PRODUCT State Association Member Price w/ Code Register
Single PDGM Webinar (1 of 7) $99 use links above
PDGM Webinar Series (all 7) $199 PURCHASE
PDGM Video (5.5 hrs) $199 PURCHASE
PDGM Video (5.5 hrs) and PDGM Webinar Series
$349 PURCHASE

PROMO CODES ARE AS FOLLOWS:

Individual Webinar Code – PDGM-Ind-MA01

PDGM Webinar Series (all 7 webinars) Code – PDGM-MA01

PDGM Video Code  –  PDGM-MA01

Combo – PDGM Video and Webinar Series (all 7 webinars) Code – PDGM-Combo-MA01

Return to www.thinkhomecare.org.

PDGM Fix Introduced, Advocacy Needed

Last week, a bipartisan group of senators, led by Sen Susan Collins (R-ME)  introduced what will be a most important legislative priority for HCA of MA this year.  Senate bill (S.433) will curtail the so-called $1 billion “behavioral adjustment” cut under the Patient Driven Groupings Model (PDGM) to which all of home health is transitioning in 2020.  Among, many other changes, PDGM will move home health from a 60 to a 30 day payment unit. This is the most significant change to home health payment since the Prospective Payment System was introduced in 2000.

The Congressional action that called for a home health payment overhaul required that the new payment model be budget neutral against current spending levels. However,  the legislation also allowed that CMS to consider “behavioral  adjustments” defined as industry actions that would be taken to increase payment under the new model, unrelated to patient case mix changes. CMS has used this authority very broadly to institute a payment adjustment in the first year of PDGM based on “assumptions” of behavioral changes, and that adjustment calls for a 6.42% base rate reduction, or a possible $1b reduction in payments.

S 433 would prohibit CMS from making any pre-rate change reductions based on assumptions and instead to phase in any adjustments (either up or down) based on observed evidence (i.e., data supported) changes in provider behavior. The objective would be to achieve budget neutrality by 2029. This later piece addresses concerns the Congressional Budget Office (CBO) expressed regarding whether a similar bill introduced last session was truly budget neutral. S.433 also would allow Medicare advantage plans and Center for Medicare and Medicaid Innovations (CMMI) to waive the “confined to home”  provision when in the best interest of a Medicare beneficiary.

Regardless of the “behavioral adjustments,” the PDGM model is expected to have a tremendously varied impact state by state and agency by agency.  A significant amount of this impact is related to a Congressional  requirement that the payment model no longer use the volume of therapy as a payment level determinant.  (Something MEDPAC has been calling on CMS to do for years.)   The state of Florida, where therapy visits average 10.45 per episode of care is set to “lose” the most – projected at $141 million.  California on the other hand, where the average therapy utilization per episode was 5.76,  will be the largest gainer.  MA (need numbers from Tim)  Note: S 433 does not seek to make changes to the structure of the payment model that produces these changes.

It is important to reflect on CMS’ proposal in 2017, Home Health Groupings Model (HHGM) and how we arrived to where we are today. At the time, HHGM represented similar changes to the payment model, without soliciting industry feedback and some estimates predicting a 15% reduction in payments. As a result, the industry unified itself behind one message: that CMS withdraw its proposal and engage stakeholders to come up with an alternative. Upwards of 13,000 emails were sent to Congress from the industry, 49 members of the U.S. Senate and almost 160 members of the U.S. House of Representatives signed onto letters to CMS echoing the request to withdraw HHGM. This was a remarkable show of mobilization by the industry and we’ll need it again to make modifications to PDGM.

At present there is no bill in the House, but it is expected that one will be forthcoming.  Strong early sign on support is critical to keeping this bill moving and HCA of MA will be urging members to contact the MA delegation to support S.433 and the companion house legislation to be introduced. Stay tuned for these advocacy alerts in our weekly newsletter and advocacy messages in the coming weeks.

HCA will also be hosting a number of member events to prepare for the payment transition.  While the full day PDGM programs in March in Northampton are sold out, there will be a high concentration of sessions on PDGM at the New England Home Care Conference and Trade Show in on June 5 -7 inn Falmouth. Watch here for more details.

In the meantime, send a message here to Senators Warren and Markey about the need for their support on this issue. 

Let’s do this home care – we cannot sustain $1 billion in cuts based on assumptions, not facts!

HCA Submits Comment on Medicare Changes; Submit Your Comments Now!

On July 1st, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule which includes several changes to the home health benefit for 2019 and beyond. The public comment period closes this Friday August 31, 2018, at 11:59 p.m. As of this blog posting, 760 comments have been submitted to CMS which is encouraging, but far from the more than 1,300 comments submitted last year in response to the HHGM proposal which was ultimately withdrawn.

You can view the HCA’s written comments here and can download the word document here.

You may submit your own comments to CMS here.

Here are some of the key changes proposed, and an overview of HCA’s response:

Home Health Wage Index Changes

  • The 2019 proposed payment rates increase by 2.1% which represents a $400 million increase.
  • HCA of MA has long expressed concerns to CMS over inequities in how the wage index is calculated for home health agencies compared to hospitals. HCA urges CMS to adjust the 2019 home health agency wage index to reflect a policy to limit the wage index disparity between provider types within a given CBSA.

Proposed Patient Driven Groupings Model (PDGM) for CY 2020

  • Implementation: As the proposed PDGM would mark a major change in the way home health agencies will be reimbursed, the HCA urges CMS to delay implementation by one year to ensure that there is no disruption in access to services for beneficiaries and evaluate the accuracy of the model and its effect.

  • LUPA Thresholds: CMS proposes to set the LUPA visit threshold at the 10th percentile for each payment group. HCA believes this is complex and will complicate the care planning process for home health agencies. HCA urges CMS to retain the current LUPA thresholds and revisit them in future years.

  • Behavioral Assumptions: CMS proposed three ‘behavioral assumptions’ in the PDGM totaling -6.42%. However, these assumptions are not based in data or evidence. HCA believes that two of the three assumptions already exist in the current PPS methodology including; that agencies are already incentivized to both report the highest playing diagnosis codes and to develop and deliver plans of care that exceed the LUPA threshold. This could result in an over estimated impact of behavioral assumptions and the HCA urges CMS to eliminate the Clinical Group Coding and LUPA threshold assumptions.

  • Split percentage payment approach: HCA believes that changing from a 60 to 30 day billing period will be very disruptive to agencies’ operations and increase back-office costs. Therefore, HCA urges CMS to continue the split payment approach at the current 60/40 and 50/50 splits for early and late periods, respectively, to give agencies cash flow breathing room.

  • Certification and Re-certification of Patient Eligibility: HCA has long advocated for regulatory language to align with sub-regulatory guidance as it relates to documentation of the patient’s eligibility. HCA is encouraged by CMS’ proposal to eliminate the requirement that the physician provide an estimate of how much longer skilled services are required and we request that CMS consider revisions to the physician’s burden of the F2F encounter as a condition of payment. 
  • Remote Patient Monitoring: HCA strongly supports the proposal to recognize remote patient monitoring costs as an administrative cost on the HHA cost report. HCA does recommend however that CMS remove the regulation that does not allow remote patient monitoring to be used as a substitute for in-person home health services. 
  • Home Health Value Based Purchasing Model: HCA has long supported the HHVBP model aiming to improve quality by giving HHAs incentives to provide better quality care. However, HCA urges CMS to modify the HHVBP to recognize stabilization in the scoring because in many cases, stabilization (instead of improvement) is an appropriate goal for some patients.