10 things you need to know about the rule CMS is proposing
No time to read 346 pages in detail? We gotcha. There’s a lot to digest in the proposed Home Health Rule for 2020 which the Centers for Medicare and Medicaid Services (CMS) made public last week.
You already know, of course, that CMS is going forward with its new Patient-Driven Groupings Model in 2020, and that specifics are spelled out in the proposed rule for calculating agency payment based on patient characteristics such as primary diagnoses, co-morbidities, admission source and functional impairment.
But there’s plenty else going on in the proposed rule. If you haven’t had the time (or the heart) to look at it yet, here’s a condensed version of 10 highlights: 1. A pay increase is proposed… CMS has included a pay increase of approximately $250 million for home health in the proposal. But keep reading, because it’s not that simple…
2. Behavioral adjustments could reduce payment. Widely criticized behavioral adjustments in the model are estimated by many industry experts to lower reimbursement by as much as 8.1 percent.
“Behavior adjustments" is a term used to describe the new payment model’s built-in expectations for how home health agencies will respond to new methodology used to calculate reimbursement.
For example, CMS expects agencies to use certain primary diagnoses which pay more. It also expects them to avoid Low Utilization Payment Adjustments by – not cheating, exactly, but somehow stretching things enough to meet visit thresholds. There’s been tremendous industry push-back against those assumptions, as they are not grounded in data, but CMS did not take them out of the model.
2. RAPs are going away.
No one is happy about this one, and there is widespread concern about potential cash flow shortages at home health agencies as CMS looks to phase out Requests for Anticipated Payment (RAPs) next year. The plan is to eliminate RAPs altogether in 2021.
RAPs are the up-front percentage of reimbursement – often as much as 60 percent of the total payment -- which is paid to home health agencies at the beginning of the episode of care. Under the proposed rule, RAPs will drop to 20 percent next year as agencies struggle to meet expedited time frames under new 30-day billing periods. Industry experts predict the financial impact could be devastating for agencies already struggling.
3. Good news for therapy utilization. CMS is proposing to allow physical therapy assistants to furnish maintenance therapy for homebound patients whose condition is not expected to improve, in order to prevent or slow any further decline. Therapy assistants are already allowed to provide restorative therapy to homebound patients if there is an expectation of improvement.
This is good news for agencies hoping to hold down salary costs to deliver more cost-effective therapy under PDGM, when therapy will no longer pay as well as some skilled nursing services.
4. A POC regulations change. Instead of denying a claim when a home care provider fails to include all the required items in a patient’s plan of care, CMS wants to approve otherwise valid claims and let surveyors deal with missing items on the POC.
Note that providers would still be required to include all items listed at §484.60 (a) in the POC. That requirement won’t change, and agencies would be subject to survey citations for not including all items. But, as long as a submitted claim meets all other eligibility requirements, it would no longer be rejected on the basis of missing POC items.
Claim reviewers would look instead to see whether the POC includes patient-specific needs identified during the comprehensive assessment and how the agency is matching services to those needs.
5. Home infusion therapy A home infusion therapy benefit is still on track to be implemented in 2021, allowing some treatments which now require patients to travel to clinics or doctor’s offices to be treated at home. Examples of those treatments include chemotherapy.
But the National Association of Home Care and Hospice (NAHC) doesn’t like this plan, saying it falls far short of creating real opportunities for home health agencies to fill this market niche. NAHC is lobbying Congress to change the way the benefit is set up.
6. Value-based performance reporting. Are you in one of the nine states included in the Home Health Value-Based Purchasing Model? Get ready for some very public competition. CMS wants to publicly report your agency’s Total Performance Scores (TPS) and percentile ranking for 2020, and would do so on a page on its web site.
Medicare-certified agencies in Florida, Massachusetts, Maryland, North Carolina, Washington, Arizona, Iowa, Nebraska and Tennessee will be affected. CMS says it expects putting this information on its web site to encourage home health agencies to do a better job and make it easier for patients and health professionals to decide whether to use an agency.
Value-Based Purchasing Model agencies will also be subject to a 6 percent pay increase or decrease in 2020, depending upon performance.
7. More SPADEs ahead. CMS devoted a lot of space in the rule to changes ahead as it continues to implement standardized patient assessment data elements, or SPADEs, across the post-acute segment of health care. Home health began using SPADEs for the first time this year, when OASIS-D introduced the new GG item set. The rule details other SPADEs which CMS plans to introduce on future incarnations of the OASIS.
Our advice: Don’t worry too much about these SPADEs just yet. Yes, they’re coming, eventually, but first there’s OASIS-D1, set to launch Jan. 1 2020. The 2020 version of OASIS is specifically designed to work hand-in-glove with the new Patient-Driven Groupings Model (PDGM.) If you need some good news right about now, here it is: The D1 version of OASIS will not be nearly as complex of an overhaul as last year’s transition to OASIS -D.
8. Goodbye, Rural Health Add-On The Rural Health Add-On is still on the way out. This small percentage payment adjustment has been made in the past to agencies in rural areas where patients may live farther apart, with substantial travel mileage required to make visits. The proposed rule shows percentage add-ons sharply dwindling in 2020-22, disappearing completely in some instances.
The Balanced Budget Act of 2018 changed the methodology used to determine the rate of the Rural Health Add-on. Beginning this year, factors such as utilization rates and population create three distinct groups with different rates, and two of the three groups will no longer receive any Rural Health Add-On by 2022.
Here are the actual numbers. In the high utilization group, the proposed rule shows the percentage at 0.5 % for 2020, with elimination in 2021. The low-density population group shows the rate dropping from 3.0% in 2020 to 2.0% in 2021 and 1.0% in 2022. In the third group, the add-on drops from 2% in 2020 to 1% in 2021 and will be eliminated in 2022.
The bottom line: Don’t count on this add-on much longer.
10. PDGM is not going to be postponed. We know. You’ve been holding onto a dim hope that CMS would change its mind and postpone PDGM. After all, there’s some recent precedent in the industry for major changes to be introduced and then pushed back. Sometimes, as in the case of the Review Choice Demonstration, the wait for an actual launch date can go on, and on, and on…. (You’re hearing us loud and clear in Florida, Texas, Ohio and North Carolina, aren’t you?)
Not this time, folks. There’s no indication that Congress will intervene in plans to launch PDGM on Jan. 1, 2020. If you haven’t begun your agency’s preparations, please reach out to us today.
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