Optimize Your Revenue Cycle for PDGM Success June 4, 2019 - - PowerPoint PPT Presentation

Optimize Your Revenue Cycle for PDGM Success

June 4, 2019

Welcome

• Introductions & format
• PDGM summary
• Revenue cycle Impact
• Preparing for PDGM
• Workflow and technology processes
• Questions

• Use the Questions section on the

GoToWebinar panel to submit questions

• Webinar will be recorded and a link

to the recording will be emailed to all registrants.

Webinar Format

PDGM Summary

Annie Erstling

Chief Strategy Officer

Erin Masterson

Consulting Manager

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Patient Driven Groupings Model (PDGM)

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• PPS:

○ 60-day episode with four

• r fewer total visits are

paid per visit

• PDGM:

○ LUPAs now have variable thresholds based on HHRG ○ Different level for each

• f the 432 HHRGs

○ 10th percentile value of visits for each threshold ○ LUPA Add-on remains

LUPAs

Billing

• For billing purposes, PDGM proposes to keep the RAP/final claim billing methodology

○ CMS estimates the median time to submit a RAP is 12 days so they are soliciting comments on if this makes sense ○ 5% of RAPs not submitted until after day 60

• New agencies as of 1/1/2019 would not receive RAP payments under PDGM but required

to submit a “no pay” RAP ○ Potential Notice of Admission in the future

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Billing

• Source of admission indicated by occurrence code on the final claim only (not included on

RAPs) ○ Medicare will automatically adjust claim if community is indicated but an institutional source submits Medicare claim

• Clinical Groupings and Comorbidity Adjustment based on diagnoses on the CLAIM, not the

OASIS ○ Up to 25 diagnosis codes can go on claim compared to 6 on OASIS

9

Miscellaneous

• OASIS still completed every 60 days
• PEPs (Partial Episode Payments) have same methodology
• Outliers have same methodology, although fixed dollar loss would need to change

○ Based on current rules, 4.77% of estimated total payments would be outlier dollars ○ CMS requirement that number cannot exceed 2.5%

• Non Routine Supply (NRS) Add-on payments eliminated

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Revenue Cycle Impact

General

• Educate all staff
• Establish strong interdepartmental communication
• Develop reporting on key indicators driving reimbursement under PDGM
• Establish internal PDGM steering committee

Key Metrics to Monitor:

• Productivity levels for all departments
• Staffing levels required to implement optimal workflows under PDGM

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Marketing

• Understand the impact of your primary referral source
• Analyze current marketing and referral relations strategies

○ Includes education to referral sources

• Determine what a “good” referral is in the future

Key Metrics to Monitor:

• Admission Percentage
• Most common clinical groupings referred by each referral source

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Intake

• Obtain as much information as possible at time of referral

○ This will be vital in supporting coders

• Strong communication with Scheduling Department
• Minimize gaps in entry of referral information into EMR

○ Develop Intake checklist

Key Metrics to Monitor:

• Productivity
• Early/Late Percentage
• Community/Institutional Percentage

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Case Management

• Interdisciplinary communication

○ Therapy still plays an important role in the care plan

• LUPA management under new structure

○ Early identification of HIPPS allows for more effective LUPA management

• Continuing assessment of patient during care

○ ROC assessment/SCIC will change HIPPS under PDGM

• Supply management

Key Metrics to Monitor:

• Turnaround time for OASIS completion/submission to CMS
• LUPA percentage
• Average length of stay
• Periods per patient
• Periods per patient

15

Coding

• Accurate and complete coding is essential
• Will determine Clinical Grouping and Comorbidity Adjustment
• Include all pertinent diagnoses

○ Up to 25 diagnosis fields available on claim; all of these will be considered when determining comorbidity adjustment

• Be aware of diagnoses that would be considered Questionable Encounters
• If significant change in condition occurs, coding may need to be updated

Key Metrics to Monitor:

• Current - what percentage of periods would fall under a QE status?
• Average number of diagnoses per claim
• Comorbidity percentage – no, low, high
• Days to RAP

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• Shorter billing period makes quick turnaround on signed orders even more important
• Timely receipt of F2F documentation also more important
• What is order submission process?
• Determine if current frequency/method of follow-up with physicians is efficient
• Education to physicians

Key Metrics to Monitor:

• Average days after start of episode that 485 is sent to physician
• Volume of interim orders generated after start of episode
• Average turnaround time for receipt of signed physician orders

Orders Tracking

Billing

• Volume of claims increases
• Shorter timeframe to resolve all pre-billing issues prior to final claim
• Monitor claims to identify Medicare processing errors
• Future of RAPs is uncertain
• Communication with coders on QE

Key Metrics to Monitor:

• Days to RAP/Final Claim
• Frequency of billing
• Claim volume on outstanding accounts receivable
• Volume of unbilled claims

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Changes in Claim Management

• CMS will calculate reimbursement based on prior claims in common working file (CWF),

diagnoses/visits on submitted claim and OASIS in QIES system, not HIPPS listed on claim ○ Need to investigate all remaining balances on A/R prior to adjusting off in EMR ○ Pricer not implemented until 1/6/2020

• Occurrence Codes for institutional referral sources

○ OC 61 – acute inpatient hospital stay ○ OC 62 – SNF, IRF, LTCH, IPF

• Occurrence Code 50 indicates assessment date
• Treatment authorization code no longer required on claims

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Preparing for PDGM

Checklist

• Educate entire staff
• Determine estimated revenue impact

○ Agency-level detail available on CMS website under “Home Health Agency (HHA) Center” provider section ○ Download PDGM grouper ○ Limited Data Set (LDS) made available by CMS

• Evaluate current agency data for key PDGM indicators
• Perform coding/OASIS audit

○ Identify potential impact of QE, comorbidities, etc.

• Evaluate current processes and workflows

○ Are these sustainable under PDGM?

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Leverage Industry Resources

• National, state organizations, and other advocacy groups

○ Attend workshops, seminars, and webinars ○ Subscribe to written publications and listservs

• There are expert organizations that can assist providers with preparation
• Consulting groups have purchased Limited Data Set (LDS) from CMS

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Workflow Processes & Technology

Process & Technology

• Success depends on people, process & technology alignment
• Review your internal processes, evaluate your teams and resources & seek out best in breed

technology solutions

• Work directly with your EHR or ancillary technology companies to determine PDGM specific

enhancements ○ What new functionality/reporting will be made available? ○ When will these new features be released for testing? ○ Will your current workflows still be viable after updates made?

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PATIENT Referrals & Intake Clinical Care Quality Data & Analytics

Finance & Rev Cycle

• Improved communication and

collaboration between cross-functional teams

• Accurate & consistent wound

measurements

• Seamless integration with EHR
• Evaluate referral sources
• Streamline intake process
• Ensure accurate and complete

intake information

• Turn intake documents into

actionable data

• Support timely and expedited

billing with clear documentation and processes

• Timely receipt of signed and

dated orders, plan of care and F2F

• Obtain electronic signatures
• Evaluate and optimize internal

processes with real-time productivity and efficiency insights

• Data model for agency specific

PDGM assessment

• Predictive revenue trending

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• Support timely and expedited

billing with clear documentation & processes

• Timely receipt of signed & dated
• rders, plan of care & F2F

Questions?

Erin Masterson Consulting Manager ErinMasterson@BlackTreeHealthcare.com (610) 536-6005 ext. 712 Annie Erstling Chief Strategy Officer aerstling@forcura.com (904) 707-2902