2020 Final Rule is out

CMS releases official version of PDGM on Halloween, and for home care providers, it's a 'mixed bag'

While the nation celebrated the spookiest holiday of the year with costumes, trick-or-treating and horror moves, home care providers got their first look at the final and official version of Medicare's new payment methodology taking effect Jan. 1, 2020. The Centers for Medicare and Medicaid Services (CMS) publicly released the official version of the Patient-Driven Groupings Model (PDGM) late in the day Thursday, when it published the Final Rule for 2020 to its web site. Many home health stakeholders and industry advisors, including Home Health Solutions Owner and President J'non Griffin, spent Halloween night looking for tricks and treats within the 511-page rule. "It looks like a mixed bag so far," J'non said. "But probably the closest thing to a 'treat' is the decision by CMS to go with a 4.36 percent behavioral adjustment in the initial year of PDGM rather than the 8.39 percent previously proposed." The percentage difference is expected to increase PDGM reimbursement for a standard 30-day period of home health care from the $1,701.73 originally proposed to $1,864.03 in 2020.

The home health industry has pushed hard for months against the CMS proposal to adjustment payment to agencies based on an assumption that they would change their coding practices and the number of home visits to maximize reimbursement. The National Association of Home Care and Hospice (NAHC) has spearheaded the resistance to a payment adjustment based on expected behavior rather than evidence. Although the advocacy organization remains opposed to behavioral adjustment, NAHC President William Dombi said in a press release this evening that the 4.36 percent adjustment for 2020 is much preferable to the 8.39 percent originally proposed. "In reducing the 2020 adjustment from 8.39% to 4.36%, CMS has given the home health community a chance to safely transition to the dramatically new payment model," Dombi said. "The behavioral adjustment remains a concern, albeit to a reduced level," he added.

Watch out for these 'tricks' While the new behavior adjustment percentage might qualify as a "treat," J'non said the official version of PDGM contains several "tricks" home health agencies will need to be aware of as they prepare for the transition just two months away. For example, CMS has tweaked some of its patient classifications in the final version of PDGM, assigning certain primary diagnoses to new clinical groupings. "Dysphagia, for example, has been added to the Neuro Rehab clinical grouping, and I87.2 has now moved to Wounds. Whatever you may have started to get a little more comfortable with under the previous methodology is going to need to be re-examined to see where it fits in the official model," she said. There's a new version of the CMS Grouper Tool for determining where patients fit into the new clinical groupings, and J'non recommends deleting all copies of previous Grouper Tools and making certain to have the latest version. "Agencies which have developed or purchased any tools will need to take a close look to see whether any changes need to be made to ensure accuracy of what they're using,” J’non said.

RAPs One of the pieces of PDGM generating unhappiness for home care providers is the phasing out of Requests for Anticipated Payment, known in the industry as RAPs. These advance payments provide agencies with up to 60 percent of an expected episode payment at the beginning of the episode.

CMS is doing away with RAPs over the next few years and will eventually require home care providers to submit a Notice of Admission (NOA) instead. Failing to submit the NOA within 5 calendar days of the start of care will generate a financial penalty for each day the agency is late. "But the submission of the NOA won't start in 2020," J'non said. "That's what CMS is working toward, with the phasing out of RAPs." Home care providers will see a reduction in RAPs next year and elimination by 2021. Some new home care providers are already prohibited from filing RAPs in 2020 as CMS sets in motion the RAP phase-out. Other than PDGM ...

Although the new payment model takes center stage in the Final Rule, the rule also includes some unrelated measures affecting home health, including a 2021 home infusion therapy benefit, quality reporting measures for home health and the Value-Based Purchasing Demonstration. Home Health Solutions will have additional coverage of what's in the Final Rule in our monthly adminstrator e-newsletter which will be e-mailed on Friday, and in our free weekly e-newsletter next Monday. Sign up to receive the e-newsletters here.