PDGM Prep: Short to-do list

Here are 5 things home care agencies need to do right now to prepare for PDGM

The prospect of a complete Medicare payment overhaul with a shorter billing period and complicated new case mix methodology may seem overwhelming, but home care agencies can ease the transition by taking some important steps now. 

The key to success is in not waiting to expedite billing processes, understand the new model and educate staff, according to J'non Griffin, owner and president of Home Health Solutions LLC.

 "We're just nine months away from the January 2020 implementation of the new Patient-Driven Groupings Model (PDGM)," J'non said. "Previous changes in Medicare reimbursement structure have proved catastrophic for home health agencies which did not make the necessary adjustments. Agencies shut down."

A PDGM 'Short List'

Here is J'non's short list of 5 important steps agencies need to take immediately as part of PDGM preparations 

1. Understand the new methodology.     From the elimination of therapy thresholds to the use of new Low Utilization Payment Adjustment (LUPA) determinant methodology, the new model will require completely different thinking on the part of agencies. It's a complex methodology, and advance education will be required to grasp the case mix variables and how they interlock to create multiple payment possibilities dependent upon unique patient circumstances. Don't wait to start reviewing the methodology.  2. Look at your patient data.      Clinical characteristics will drive reimbursement under the new model. To assess the financial impact of PDGM, each agency will need to analyze its unique patient population to determine whether it trends toward higher-paying or lower-paying variables under the model. In some cases, agencies may find that they are consistently serving patients for whom the highest reimbursement is provided under the new model. In other cases, agencies may need to seek a better balance of patients by expanding their referral sources. 

In particular, look at:

  - Primary diagnosis codes and comorbidities.  Patients will be placed into clinical groupings by diagnosis, and some common home health diagnoses such as "weakness" or "debility" will no longer be allowed. The underlying medical condition will determine the clinical grouping. The new model also allows for certain comorbidity adjustments, and it is important for agencies to understand how these variables work together in a complex system. 

  - Admission sources. Institutional sources generally will provide higher reimbursement rates than community sources, as CMS expects patients admitted to home health after acute care to be sicker, in general, than patients from other sources. But not every visit to a hospital is considered institutional. Two exceptions, for example, are emergency room visits and observational stays. Patients discharged to home health after either will be designated community admission source. 

  - Visit patterns. An evaluation of visit patterns and trends will help agencies determine where they fall on the new model. In some cases, agencies may need to rethink visit thresholds.

3. Expedite your billing processes now. Under PDGM, the current 60-day billing period shortens to 30 days, although the episode of care will remain the same. Expedited processes will be needed to adjust to the shorter timeframe. Agencies need to work with staff now to streamline workflow and identify issues that need to be resolved before the new model takes effect. This includes working with referral sources to achieve shorter timeframes for signatures.  4. Educate referral sources. Preparing physicians and referral sources for the new PDGM is going to be challenging, and agencies need to begin now. If you're not sure which information to get to physicians, be sure to check out the $19.99 Tough Talk Tools package in the HHS online store. This package provides tools which can be taken to referral sources as part of in-person meetings to discuss the new payment model. It features a printable brochure with concise, easy-to-understand points explaining the physician's new role under PDGM, including important changes in timelines and primary diagnoses. There's also a handout featuring a list of common home health diagnoses which will not be allowed under PDGM.  

5. Need help? Just ask us!  If you're feeling intimidated by the enormous changes ahead, we can help. We can provide the customized education you need to identify your agency's weaknesses and prepare your staff. HHS can provide all the services necessary to make a successful transition. Reach out to us today!