The RCD and PDGM Trifecta

Your agency should focus on these 3 areas for success under a convergence of Review Choice and PDGM

Home care providers in Ohio will begin signing up this week for either pre-claim or post-payment reviews as the Centers for Medicare and Medicaid Services (CMS) expands its Review Choice demonstration to a second state.

Friday will be opening day for the selection process in Ohio, with Medicare administrative contractor Palmetto GBA accepting agency choices in preparation for a Sept. 30 launch date.

Ohio agencies may choose to forego pre-claim or post-payment reviews, but will incur a 25 percent penalty on all Medicare reimbursement if they forego reviews, and still be subject to some minimal post-payment review. If a home care provider fails to select any of the three options by Sept. 15, Palmetto will place the provider by default into the post-payment review process.

Review Choice has been underway in Illinois since June. Home care providers in Florida, Texas and North Carolina have been told by CMS they will go next and are still awaiting the timeframe.

The timing of the expansion to Ohio dashed any lingering hopes in the home health field that CMS might postpone Review Choice to give home care providers in targeted states time to adjust first to major changes ahead under the new Patient-Driven Grouping Model (PDGM) taking effect Jan. 1, 2020.

“It appears that CMS is ready to go forward quickly with Review Choice despite PDGM, and agencies in Florida, Texas and North Carolina could find themselves in Review Choice at almost the same time they are implementing PDGM,” said J’non Griffin, owner and president of Home Health Solutions.

How successfully home health agencies are able to handle the convergence of new 30-day billing periods under PDGM and the Review Choice demonstration may depend in large measure on three factors, according to J’non and other team leaders at Home Health Solutions.

Together, these three factors make up a sort of “trifecta” of Review Choice and PDGM success.

“In the world of horse racing, a trifecta occurs when you pick the three winning horse and the order in which they will finish,” J’non said. “Of course, in the world of home health, all three horses need to finish simultaneously to ensure success – and by the way, all three horses needed to have been on the track yesterday or you’re already running behind.”

Here are the HHS team’s three tips for Review Choice/PDGM success:

1. Get faster.

Whatever you’re doing now, you’re almost certainly doing it too slowly.

“One of the largest impacts of both PDGM next year and the pre-claim review option under Review Choice will be the way these major changes force home health providers to simply move faster,” J’non said. “With 30-day billing periods under PDGM, and the need to get together all documentation faster under a pre-claim review process, agencies are not going to have any time to waste in collecting the necessary items and making sure things are done correctly the first time. Smart agencies are already working on these problems right now, trying to identify problems and speed things up before the changes take effect.”

That means getting referral sources on board with expedited timeframes, too.

“The agencies which have the most success with these huge changes are going to be the ones who are out there right now explaining to their referral sources what is going to happen next year, and the need for expediency,” said Home Health Solutions Director of Clinical Services Apryl Swafford. (HHS sells a brochure template to help agencies explain PDGM to their referral sources.)

In some instances, Apryl said, success with expedited timeframes may even mean cutting ties with some referral sources.

“That’s an unpleasant and unpopular consideration, but it may have to happen in certain circumstances when the referral sources aren’t interested in changing the way it’s always been done,” Apryl said. “Otherwise, the agency isn’t going to get paid for those claims with primary diagnoses which aren’t allowed or missed timeframes.”

It’s also important for agencies to get their staff members on board with new timelines.

For example, many clinicians may not have previously felt a sense of urgency in scheduling a doctor’s visit for a new home health patient to meet the requirement for a face-to-face encounter between patient and physician related to the main reason for home health. After all, Medicare allows up to 30 days after the start of care for the F2F encounter to occur.

New 30-day billing periods, however, mean agencies won’t be able to wait as long to get the F2F visit scheduled and obtain the necessary clinical encounter note from the physician.

2. Old-school chart reviews.

One worrisome aspect of trying to do things faster is the increased likelihood of errors and omissions – which could be particularly detrimental to an agency’s pre-claim affirmations.

Heather Calhoun, Director of Special Projects and Appeals at Home Health Solutions, recommends placing someone in charge of in-house auditing to scour charts for problems.

“You will have to make sure all those dots are connected,” Heather said. “Are all the necessary pieces in place and do they tell the complete story? Are there any gaps in the information? Are different physicians involved? Is the certifying physician different from the physician who conducted the F2F? Are all the dates and signatures there?”

Nothing is as effective in error control as having standard procedures in place to review every chart before claims are filed (or pre-claims submitted), Heather said.

“Chart audits may be the single most important way an agency can ensure success under Review Choice,” said Randy Weisheit of PIChart Audit. His company markets a chart audit tool to simplify chart auditing, making it faster and cost-effective.

“You want to be able to track percentages of completion and know exactly what is happening within your organization so that you can get these potentially costly errors corrected,” Randy said. “Where are your consistent omissions? Who on your staff may benefit from some additional training? These are issues of particular importance when you have multiple branches, so that you can make the best use of your resources and focus additional training where it is really needed.”

3. Ask for help.

With so many demands and significant changes ahead, many agencies are feeling overwhelmed. There’s plenty to worry about from potential cash shortages during transition periods as shorter billing cycles take effect in early 2020 to potential problems in staff retention and staff morale.

“No one should be reluctant to seek help with any part or all of this,” J’non said. “In fact, the smartest thing an agency can do as it looks ahead to Review Choice and PDGM is to assess its own shortcomings and weaknesses and look for areas where it can benefit from some help. Maybe the agency just needs some transitional help with education and training to better understand how to make these huge adjustments. Maybe the agency needs to look at a complete restructuring and possible outsourcing of some services. Each agency is different, and will be affected differently. But a willingness to get help may be the single most important determinant of an agency’s ability to successfully navigate the changes ahead.”

If you’d like to talk to Home Health Solutions about how we can help, contact us today! We’re friendly, knowledgeable and eager to help.