Hundreds of new LUPAs are possible under PDGM. Here's how home care providers can control them.
Does your home health agency know exactly what's causing its Low Utilization Payment Adjustments, known as LUPAs? If not, a little diagnostic work may be needed before Medicare's new Patient-Driven Groupings Model takes effect in January, according to Apryl Swafford, Clinical Director at Home Health Solutions.
Under Medicare's current payment model, home care providers are penalized with a payment adjustment if they provide four or fewer visits during any 60-day episode of care. Instead of being paid the regular amount for a full episode of care, home care providers receive a standardized amount for each of the four or fewer visits. Under PDGM, the number of visits qualifying for a LUPA will vary by clinical grouping and patient characteristics, creating hundreds of opportunities for a LUPA to occur. "One of the complexities within the new payment model will be its treatment of LUPAs, with the number of visits qualifying as a LUPA different for each one of PDGM's 432 possible case mix adjustment payment groups," Apryl said.
"LUPAs will be as highly individualized for each patient as all the other aspects of the new payment model, and the LUPA threshold will vary from two to six visits within each of the new clinical groupings based on patient characteristics," she said. Industry apprehension Home care providers attending the PDGM training sessions Apryl is leading across the country are particularly apprehensive about LUPAs because the new methodology provides so many variations. "It can be intimidating," Apryl said. "This is a huge change and will require a completely new mindset when looking at the number of visits." The LUPA threshold for a patient under PDGM will be calculated by factors such as primary diagnosis and comorbidities, whether the admission source was community or institutional, whether the episode's timing is considered "early" or "late," and the patient's level of functional impairment.
Looking at the cause Agencies with high LUPA rates should use the next six months to carefully evaluate and identify the causes, and implement any operational changes necessary to curb their LUPA rates, Apryl said.
Many different factors can cause a LUPA, from missed visits by the agency to a limited need for agency services. In some cases, LUPAs may be unavoidable, Apryl said. A patient may need certain limited services outside the scope of a usual episode such as a monthly Foley catheter change. Some patients may be readmitted to the hospital or a different facility and never return to the home care agency's care. A patient may decide to "fire" the home health agency and refuse any additional care. Tips for avoiding LUPAs
But there are certain things agencies can do to put the reins on LUPAs in preparation for PDGM, and Apryl recommends agencies take these steps as soon as possible, to make the transition to PDGM easier. 1. Use schedulers.
Visits should be managed by schedulers who are knowledgeable about thresholds based on individual patient characteristics, and whose specific responsibility is to oversee utilization for efficiency and make any adjustments necessary to avoid missed visits.
2. Be careful when frontloading. Frontloading visits, particularly for at-risk patients newly released from the hospital, is a recommended best practice for agencies attempting to minimalize a patient's risk of readmission to the hospital. It has the potential to create more LUPAs under PDGM, when episodes of care will be billed in 30-day cycles rather than 60-day cycles. Schedulers should always consider the impact of frontloading on the second 30-day billing period when planning visits. Is it possible to provide the patient's care more efficiently within the first 30-day period to avoid creating a LUPA in the second 30-day period?
3. Train your staff.
It is crucial for agency staff to understand all aspects of the new PDGM for successful implementation, Apryl said. Understanding how a missed visit could potentially impact the agency's reimbursement by creating a LUPA will help with staff "buy-in" and be more likely to reduce the number of visits rescheduled for the convenience of the agency. We can help! If you'd like to discuss PDGM training for your staff, or schedule consulting to better understand how LUPAs could impact your agency, contact us today! Our friendly and knowledgeable staff would love to help you prepare for PDGM.