Part 2 — Sustaining Financial Health Under PDGM: Your EHR Can Help

May 23, 2019 Liza Markling

In my previous post, I reviewed some of the information shared in HomeCare’s recent webinar, “Sustaining Financial Health Under PDGM.” Ron Barrera, Director of Financial Consulting for Simione Healthcare Consultants, and I discussed how home health agencies (HHAs) can prepare for Medicare’s new Patient-Driven Groupings Model (PDGM) rule coming in 2020. My previous blog post provided details on the importance of analyzing your reimbursements in terms of clinical groupings and visit frequencies as you prepare for PDGM. Now, let’s take a look at the remaining areas in which you should compare your reimbursements under the current Prospective Payment Systems (PPS) versus the upcoming PDGM rule:

  • Source and Timing
  • Visit Utilization
  • Episode
  • Revenue Cycle

Educate All Staff About Source and Timing    

In the PDGM world, your staff — from intake to clinician to billing — will need to be in lockstep regarding your procedures around the source and timing of each episode. Your EHR can be invaluable during the eligibility verification process. The PointClickCare solution performs an automatic real-time verification check against the Common Working File (CWF) during intake, as well as throughout the episode. It not only substantiates overall eligibility, but verifies recent home health admissions. This will enable your intake person to understand the early/late timing of the episode and where the patient has been in the past 14 days.  

The EHR will create a feedback loop between your intake and billing staffs:

  • It will record the admission source and attach the related paperwork during intake or Start of Care (SOC).
  • It will confirm the admission source prior to the creation and submission of the billing claim enabling your agency to receive the correct institutional reimbursement.
  • It will alert you to add the Occurrence Code on the claim if the episode is an institutional admission.

Your billing department will especially appreciate these verifications, since it will have its hands full trying to bill twice as many claims per episode as they do today.

Visit Utilization Plan Will Benefit from Remote Monitoring

With the tiered levels of therapy reimbursement going away under PDGM, you may want to evaluate the way in which you use therapy visits. You still need to manage the patients to achieve the best outcomes for them, but you may use other disciplines to reach those goals. Technology options will help you in this process, particularly remote monitoring products. Although not covered by Medicare (yet), remote monitoring and telehealth allow you to provide the right care at the right time. They can also drive better outcomes by focusing on the optimal disciplines and frequencies. Be careful not to make too drastic of changes around therapy utilization, as CMS is monitoring for behavioral changes, but it would be good to at least be aware of how you’re using therapy today and how you might want to make changes in the future.

Episode Distribution: It’s All About the LUPAs

Your EHR can provide you with ongoing metrics and analysis of episodes, beginning with a look at your episode distribution today and how it will change with the new Low Utilization Payment Adjustment (LUPA) thresholds. LUPAs today are always four or fewer visits, but under PDGM, the LUPA threshold varies between two and six visits. PointClickCare focuses on this area by monitoring episodes throughout the application — full episodes, outlier episodes, LUPAs, and partial episode payments (PEPs) — so you can determine your target going forward. Our solution can:

  • Display the LUPA thresholds to all users — coder/quality assurance, clinician, scheduler
  • Confirm the progress toward meeting the LUPA threshold
  • Track missed visits and alert you if the missed visit will cause a LUPA

A piece of good news: the six-visit LUPA threshold is only in the early clinical groupings, so you won’t have to be concerned about needing at least six visits in the second 30-day period.

Revenue Cycle Management Can Be More Efficient

The automated workflows in your EHR can actually help you reduce the overall length of time it takes to bill claims and collect payments. With requirements tracking, automatic claim generation, electronic claim submission, and electronic remittance, your EHR helps you build and submit timely claims. If you’re using this information correctly, you should be ready to submit a Request for Anticipated Payment (RAP) as soon as you get to the second 30-day period of an episode. That would help with cash flow, since you will no longer receive the 60-day amount upfront with the first RAP. Also note that only existing agencies as of January 2019 will be eligible for a RAP payment under PDGM. New agencies will still need to submit a RAP, but will not receive a RAP payment.

It’s All About the Patients

Yes, the clock is ticking towards PDGM, and everything you do now to prepare will make the changes easier for your agency to manage. Take advantage of the tools available to you, involve and educate all of your staff, and track and test what you can before next year. And remember that patient outcomes must always be front of mind: how do you adjust for the new rules while continuing to help the people you serve achieve the best possible results? You’ve got this!

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Part 1 — Sustaining Financial Health Under PDGM: Your EHR Can Help
Part 1 — Sustaining Financial Health Under PDGM: Your EHR Can Help

In HomeCare’s recent webinar, “Sustaining Financial Health Under PDGM,” I joined with Ron Barrera, Director...