Maximize your reimbursement

Here's how the Simione-Home Health Solutions merger can build a sturdy foundation for your agency’s profitability.

Structuring your organization for maximum profitability under Medicare’s complicated regulatory environment can feel as tricky as building a large, complex tower of cards. No matter how far you’ve come, a weak link can place the interlocking structure at risk of toppling.

The same basic principles for success apply whether you’re building a profitable agency or an intricate card structure, according to two leading post-acute health care industry experts with decades of experience at getting it right.

Success starts with a sturdy foundation – and builds on itself when each interlocking piece efficiently supports the whole, according to William J. Simione III, Managing Principal of Simione Healthcare Consultants, and J’non Griffin, Founder and President of Home Health Solutions.

The two companies announced their merger earlier this week, blending and strengthening their professional services to create a formidable new industry authority for clients seeking to maximize reimbursement and effectively grow their organizations.

Is success in the cards?

Profitability is the sum of its parts, according to Simione.

“Any time we investigate what is hindering an organization’s financial success, we almost always uncover process or system issues that are either creating or contributing to the organization’s overall financial problems,” he said.

An agency looking to generate maximum reimbursement will need to fully examine its clinical and operational aspects to see how well they support the financial piece, he said. Is scheduling on target to prevent LUPAs? Is communication taking place among coders, clinicians and billers?

“We offer a comprehensive, integrated approach to solving problems for agencies, realizing the value of a holistic method to profitability,” Simione said.

The importance of interlocking cells to an organization’s overall success isn’t unique to home health. Even the performers who compete to build professional towers of cards say the most stable way to build large, complex card houses is by using a basic four-card cell they call a “lock box.” Each card supports the others in a structurally stable foundation and enables the card tower to stretch skyward. Guinness World Records lists the tallest at over 25 feet.

“And that’s just four little cards working together, building on each other, supporting each other and repeating that integrated level of support at each level,” Griffin said. “How much more can your agency accomplish when you have all the pieces in place for your departments to support and build on each other?”

A four-sided “lockbox”

Using the card tower analogy, here’s a basic “lockbox” of four components both Griffin and Simione see as a necessary foundation for maximizing reimbursement at an agency.

1. Coding and OASIS under PDGM

Agencies have always required competent coders for maximum reimbursement, but the difference between basic coding competency and coding which meets new PDGM specifics can significantly impact episode payments.

Medicare’s new payment model, the Patient-Driven Groupings Model (PDGM), is a complex system in which episode payments are based on the interrelated characteristics of patients, including their co-morbidities and functional limitations. Accuracy requires greater specificity, clinical understanding and a solid grasp of how the new payment model works.

Home Health Solutions maintains an experienced staff of certified coding and OASIS specialists who are knowledgeable about PDGM.

“We’re particularly excited about the opportunity our merger with Home Health Solutions offers to clients in need of professional coding and OASIS services as part of a multi-dimensional approach to address their financial challenges,” Simione said.

2. Referral and intake processes

Case mix under PDGM can significantly impact an agency’s reimbursement, and many agencies are still struggling to make a lucrative case mix adjustment now that patient specifics have replaced therapy volume as the revenue driver.

Simione has in place all the resources to improve referral management, with consultants who can help agencies identify the case mix changes that need to be made to address reimbursement losses. Both virtual and on-site training opportunities are offered for sales and marketing efforts to capture new referrals.

Getting the referrals is just part of the story. A successful intake process must include communications and specific information collection from physicians under new timeframes and more stringent PDGM requirements. Simione can identify the organizational changes and training needed to turn around reimbursement losses throughout the admissions engine.

Intake processes will become even more important in 2021, when the Centers for Medicare and Medicaid Services (CMS) plans to make significant changes to Request for Anticipated Payment (RAP) procedures. Although the upfront payment will no longer be made to agencies, the RAP will be required to establish the home health period of care in the common working file and trigger consolidated billing edits. Timely submission of a RAP – within the first five calendar days after start of care – will be required for each 30-day period, and failure to comply will result in significant reimbursement losses for the agency. This important change will require new training and shifts in processes for most agencies.

3. Clinical Documentation

From the initial comprehensive assessment to each individual visit note, an agency’s clinical documentation should be a sturdy framework displaying all the patient-specific information necessary for accurate reimbursement. Do your clinicians understand how to fully capture ongoing medical necessity for skilled services midway through the episode of care, or near the end?

Together, Simione and Home Health Solutions offer an array of customized education programs and audit tools designed to improve clinical documentation, avoid losses and denials, improve patient care and team communication, and engineer better patient outcomes.

4. Improved billing processes

Even when an agency’s clinical documentation is sound, billing processes can create opportunities for denials and reimbursement losses. With PDGM’s 30-day billing periods forcing agencies to expedite their billing processes, important inter-departmental communications can sometimes be overlooked and impact coding accuracy.