Preparing for PDGM: A Must-Do Checklist to Evaluate Your Agencys - - PowerPoint PPT Presentation

Preparing for PDGM: A Must-Do Checklist to Evaluate Your Agency’s Readiness

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• PDGM Framework
• General Checklist
• Revenue Cycle

Overview

August 2018

PDGM Framework

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• IPS: 1998 - 2000
• Reduced per-visit payment rates
• Established beneficiary cost limit for home health

agencies

• PPS: 2000 – 2019
• Introduced episodic billing (60-day episodes)
• Refined in 2008
• Reimbursement based on episode timing,

clinical/functional OASIS scores, therapy volume, and supply volume

• PDGM: Beginning 2020
• Reduces billing period to 30 days
• Aligns reimbursement with resource use

Medicare History

PDGM Details

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• Implementation date proposed to be for periods of care

beginning on or after January 1, 2020

• Budget neutral – huge win compared to the estimated

$950M reduction in payment of HHGM

• Replaces 60-day payment episodes with 30-day periods
• OASIS still only required every 60 days
• Return of sudden change in condition (SCIC)

adjustments

Summary of Changes

What is PDGM?

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• Eliminates the use of the number of therapy visits in

payment determination

• Increase total number of case-mix weights from 153 to

432

• Modification to visit thresholds for low utilization

payment adjustments (LUPAs)

• Model based on claims and cost report data
• Estimated 959,410 (14.2%) claims excluded due to non-

linked OASIS

• 7,458 cost reports

Summary of Changes (Cont’d)

What is PDGM?

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What is PDGM?

Patient-Driven Groupings Model

General Checklist

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Preparing for PDGM

General Checklist

• Educate staff in all departments
• Determine agency’s estimated revenue impact
• Understand which PDGM components will have the

largest impact on your agency (positive and negative)

• Prepare/budget for cash flow delays during PDGM

transition

• Contact your Senators and Representatives to support

legislation to eliminate the behavioral adjustment (8.01%)

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• Create an internal PDGM steering committee
• Develop reporting on key indicators driving reimbursement

under PDGM

• Evaluate current processes and workflows
• Are these sustainable under PDGM?
• Perform a coding/OASIS audit
• Identify potential impact of QE, comorbidities, etc.
• Establish strong interdepartmental communication

General Checklist

Operational Impact

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• Contact your EMR and ask what they are doing to prepare
• 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 EMR

updates made?

• Documentation Management/Orders Tracking
• Facilitate compilation, storage, and review of referral

documents

• Streamline start of care workflow
• Allow for documentation to be analyzed based on specific

categories (i.e. referral source)

• Maximize use of e-fax or electronic communication

Leveraging Technology

Preparing for PDGM

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• HCA NY, NAHC, and other advocacy groups
• Several seminars, webinars, and workshops available
• There are expert organizations that can assist providers with

preparation

• Consulting groups have purchased Limited Data Set (LDS) from

CMS

Leveraging Industry Resources

Preparing for PDGM

Revenue Cycle

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• Understand the impact of your primary referral

source

• Analyze current marketing and referral relations

strategies

• Includes education to referral sources
• Obtain as much information as possible at time of

referral

• Strong communication with Scheduling

Department

• Develop Intake checklist

Intake

Operational Impact

Key Metrics to Monitor

• Percentage of current referrals that are institutional vs. community
• Most common clinical groupings referred by each referral source

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• Determine appropriate visit frequency at

start of care

• Therapy still plays an important role in

the care plan

• Streamline identification process for HIPPS
• Allows for more effective LUPA

management

• Ensure timely completion of OASIS/visit

documentation

Patient Management

Operational Impact

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• Establish processes to continuously

assess patient during care

• ROC assessment/SCIC will change

HIPPS under PDGM

Patient Management

Operational Impact

Key Metrics to Monitor

• Turnaround time for OASIS completion/submission to

CMS

• Estimated LUPA percentage under PDGM
• Average length of stay

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• Accurate and complete coding is

essential

• Will determine Clinical Grouping

and Comorbidity Adjustment

• Develop strong education back to

clinicians on issues identified in coding/OASIS audit

• Include all pertinent diagnoses – up to

25 on claim

Coding

Operational Impact

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• Be cognizant of diagnoses that fall under the

Questionable Encounter (QE) classification

• Estimated 14% of periods would be

classified as a QE in current claims data set

• If significant change in condition occurs,

recognize that coding may need to be updated

Coding

Operational Impact

Key Metrics to Monitor

• What percentage of periods would fall under a QE status?
• What percentage of periods would qualify for a comorbidity

adjustment?

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• Shorter billing period makes quick

turnaround on signed orders even more important

• Incorporate face-to-face documentation into
• rders process
• Plays a role in accurate coding and

timeliness of billing

• Evaluate how quickly agency is getting new
• rders to physicians
• Minimize use of hard copy mail

submissions

• Minimize delays in checking signed orders

into EMR

• Educate physicians on new regulations and

increased urgency on orders receipt

Orders Tracking

Operational Impact

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• Establish streamlined process for following

up on outstanding orders

• Follow-up at the physician level
• Reach out to physicians every seven (7)

days until orders are returned signed

• Utilize phone calls on top of

resubmission of orders

• Develop escalation process if orders not

being signed (i.e. courier)

Orders Tracking

Operational Impact

Key Metrics to Monitor

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

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• Ensure all supplies are still added to claims/cost

reports

• These will be factored into rate setting for

clinical groupings

• Remain cognizant of the differences in

reimbursement between clinical groupings

• CMS will allow for remote patient monitoring on

cost reports

• How does this factor into care delivery, case

management, and supply utilization?

Supply Management

Operational Impact

Key Metrics to Monitor

• Timeliness of supply entry into EMR
• Delays in billing due to untimely entry of supplies
• Volume of claims submitted without appropriate supplies included

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• Evaluate if staffing levels/productivity

can support increase in claim volume

• Streamline pre-bill audit process to

account for shorter timeframe to resolve issues prior to final claim

• Monitor claims to identify Medicare

processing errors

• Analyze impact of RAP changes
• Payment decreased to 20% of

expected amount in 2020

Billing

Operational Impact

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• Develop strong communication of

billing issues to other revenue cycle departments

• Maintain strong non-Medicare

collections processes to help support agency during cash flow interruption

Billing

Operational Impact

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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• Adapt accounting model to 30-day period

format

Finance

Operational Impact

Questions?

Brian Harris Consulting Director BrianHarris@BlackTreeHealthcare.com (610) 536-6005 ext. 732

Consulting Outsourcing Education

Mike Freytag Managing Principal MikeFreytag@BlackTreeHealthcare.com (610) 536-6005 ext. 704