Getting referral sources on board

Strategies to make sure physicians and facilities get on board with PDGM changes

One of the most challenging aspects of adapting to Medicare’s new payment model is proving to be something over which the nation’s home care providers have little control: how their referral sources respond to the new regulations.

Many home health agencies prepared for this year’s launch of the Patient-Driven Grouping Model (PDGM) with detailed intake processes designed to head off non-specific diagnoses, generate faster turnaround times for physician signatures and make sure a valid and timely face-to-face encounter occurred between patient and physician.

But old habits die hard, and some physicians and facilities haven’t been as receptive to PDGM requirements as agencies would like.

“We’re hearing from many agencies that they’re getting a lot of pushback from their referral sources,” said J’non Griffin, owner and president of Home Health Solutions, a nationwide outsourcing and consulting firm. “Even the agencies which tried to prepare their referral sources for PDGM are telling us that those proactive education efforts just haven't worked with some of their providers.”


To be reimbursed by Medicare, home care providers have no choice other than to abide by PDGM’s new 30-day billing periods and more specific diagnoses requirements – with or without cooperation from their referral sources.

In some cases, agencies may have to take the difficult step of declining patients from a provider who shows no interest in following the new rules, J’non said. And in almost all cases, home care providers need to keep talking to referral sources about the changes.

“There's an old marketing adage known as The Rule of 7, which says most people need to hear or see a message at least seven times before they are willing to act on it,” J’non said. “People are forgetful and easily distracted by their own issues and concerns. They’re used to doing things a certain way, the way they’ve always done them.”

Realizing that it can take at least seven times for a message to sink in may shed some light on a referral source’s reluctance to make the necessary changes, J’non said.

“Think about it for a minute. Have your referral sources been told at least seven times what is expected of them under PDGM how important this is, and why? If you’ve only shared information about PDGM once, twice or even three times with a referral source, it may be unrealistic to expect that source to be willing to act on it. ”


Here are seven strategies to help get your referral sources on board.

1. Be clear about what is expected. If your marketing team cannot articulate what is and what is not allowed under PDGM clearly and concisely, don’t expect your referral sources to figure it out on their own. Make certain your sources know exactly what is expected of them.

· When is the timeframe for all signatures?

· Which diagnoses are not acceptable and why?

· What constitutes a valid face-to-face encounter? There are different requirements for facilities and community physician referrals, and your staff needs to know the difference and be able to clearly state what is needed from different sources.

2. What are the consequences? When you want someone to take an action, you must be 100 percent clear about what will happen if they don’t. In this case, you will be unable to provide the care and services needed by the vulnerable homebound patient, as CMS will not reimburse you. Your referral sources will need to understand that delays due to errors with referrals will have a direct impact on the patient.

3. Provide copies of regulations. Seeing is believing, especially when it comes to the Federal Register. You may want to have a copy of the Final Rule available to show what CMS says about 30-day billing periods and diagnosis specificity.

This can be particularly helpful when a vague symptom code is offered because “there is no definitive diagnosis yet.” CMS made it clear in the Final Rule that it expects patients to have a definitive diagnosis by the time they are home health patients. Your agency did not make that rule; CMS did.

If your referral source is also providing pushback about allowing a nurse practitioner or a physician’s assistant to certify the home health patient or write orders, it is helpful to have on hand the section of the Social Security Act which specifies who is allowed to certify the patient. In many cases there is confusion about who is allowed to do what, as NPs and physicians ARE allowed by CMS to conduct the face-to-face encounter, and legislation has been proposed to allow them to refer patients to home health. Showing the law as it currently stands will settle this issue and close the debate.

4. Be consistent and repetitive. Repetition aids recall – so look at every glitch as a learning opportunity. Did the physician refer a patient to your agency with a non-specific primary diagnosis such as abnormality of gait, generalized weakness or back pain? Did the case manager at the skilled nursing facility send you paperwork that has more to do with the patient’s dietary needs than his condition at discharge – and call it a face-to-face encounter?

Be ready to follow up immediately with educational efforts.

Have in place a letter reiterating Medicare’s new requirements under PDGM, citing what the Final Rule says about diagnoses, and make certain it gets to the physician each time a patient cannot be referred because of a diagnosis issue. Have another letter in place explaining to the SNF case manager exactly what is needed for a valid face-to-face encounter.

When these issues occur, make sure those letters get mailed or hand delivered promptly, and your agency follows up the letter each time with a phone call or an in-person visit to answer questions. When the referral source gets the same prompts each time, the message will get through.

5. Do things their way. Having trouble getting physicians to meet deadlines for PDGM’s 30-day timeframes? Frankly, from the perspective of the physician, you can be a real pest, a bottomless void for signatures.

In her recent webinar on “Orders Management Under PDGM,” Home Health Solutions team member Kim Wilkerson encourages agencies to look at expediting signature collection by making it as painless as possible for the physician. She recommends tailoring the process for each referral source to meet individual preferences.

“Ask how they want it done and then keep detailed notes – a cheat sheet, really - about what works best for that physician as far as getting orders back in a timely fashion,” Kim said. “Do they prefer a FAX? Do they prefer it to be hand delivered? Do they prefer hand delivery but only on Tuesdays? Write it all down in a file.”

One important notation for the cheat sheet is the name of the person will be responsible for making certain the physician signs the order, Kim said. “Remember, it’s not they didn’t get it. It’s that they didn’t get to it. Always follow up with the right person.”

6. Tighten up where you can. Most agencies have multiple outstanding orders awaiting signatures at any given time for every single patient – but are all those physician’s orders actually needed? Maybe not. In some cases it’s agency routine rather than regulations that prompt the order, and the wait for the physician’s signature isn’t really needed.

Agencies have been drilled in the need for physician orders for everything they do – and rightly so, in most cases. But there are times when no order is needed.

“One example would be when services cease because of the death of a patient,” Kim said. “Another might be when a visit to a patient is missed, or when the therapy re-eval does not identify the need for any changes in agency services. None of these require an actual physician’s order, but I see agencies all the time believing that they have to have a signed order under these circumstances.”

She cautions that proper documentation is required for the examples she provided. “New Conditions of Participation, for example, do require agencies to notify the physician when a visit is missed for any reason – but they don’t require a signature,” Kim said. “You’ll need adequate documentation, but you may be able to avoid the wait for a physician’s signature. And one less signature is a good thing.”

Kim recommends agencies look for ways to consolidate orders so that fewer signatures are needed and avoid unnecessary signatures when effective documentation will suffice instead.

(Interested in a recording of Kim’s webinar on “Orders Management Under PDGM”? It’s sold in The Solutions Shop, the HHS online store, along with our digital list of 12 Timesavers Under PDGM, for $34.99) Click here for more information.

7. Don’t back down When you are hearing “No one else requires this,” it’s easy to feel as if you are about to lose that referral to other home health agencies with less stringent demands. You may start to second guess yourself -- but don't.

Perhaps the person making that statement has not been paying attention. One thing is for sure. If other agencies are not yet requiring it, they will be -- or they'll be out of business soon enough, unable to pay salaries and office rent when their Medicare claims are consistently denied.

Don't be discouraged when you run up against the "You're the only one!" wall, because you are not the only one. PDGM changes affect all home health agencies. Referral sources will eventually come around to this new way of doing things because they have no choice, if they want to continue arranging home care and services for their sick patients. The more you help to educate your referral sources, the faster the overall changes in home care referrals will occur.

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