[PPT] - Using PDGM Data to Forecast Your Fiscal Impact & Budget for 2020 PowerPoint Presentation

SLIDE 1

Using PDGM Data to Forecast Your Fiscal Impact & Budget for 2020

HCA Senior Financial Managers Retreat Presenters:

Rob Simione, CPA, Director of Finance

SLIDE 2

Patient-Driven Groupings Model (PDGM)

2

SLIDE 3

Overview – Proposed Rule

Who
Effects all Home Health Agencies
What
Change from payment of 60-day episodes to payment of 30-day Periods of Care.
Elimination of Treatment of Therapy Thresholds
Phase out of RAP Payment
Biggest change since 2000 with the implementation of PPS
When
For episodes beginning on or after January 1, 2020
Why
Better Align Payments with
Patient Needs
Better ensure that clinically complex and ill beneficiaries have adequate access to

home health care

Budget Neutral

3

SLIDE 4

4

PDGM Architecture

*CMS-ABT PDGM Model 2018

SLIDE 5

Proposed Behavioral Adjustment/Rates

SLIDE 6

New York Comparison

6

PPS vs. PDGM Summary Comparison

Benchmarks PPS Reimburesement PDGM Reimbursement Variance Change New York 485,496,174.00 $ 509,963,812.00 $ 24,467,638.00 $ 5.00% National 16,259,831,351.00 $ 16,260,262,302.00 $ 430,951.00 $ 0.00%

SLIDE 7

Budgeting Under PDGM Case Study

7

SLIDE 8

Budgeting Needs Buy In!

Everyone should be involved.
Executive Management
Clinical Directors
Financial Directors
Sales and Marketing
Quality
Need buy in from everyone when it comes to budgeting review.
Goals/expectation have to be realistic and fall in line with Quality Care.
Realistic expectation for growth and staffing.
What can we expect right away and what can we expect to improve as we

adjust to the new model!

Where is the opportunity!

8

SLIDE 9

PDGM Data Gathering

9

Total Medicare admissions
Monthly Medicare admissions (seasonality vs. stability)
Sequence of periods by clinical grouping (includes

questionable encounters)

Reimbursement by period by sequence by clinical group
Reimbursement per period for 1st 30-day periods
Reimbursement per period for subsequent 30-day periods
Visits by discipline by period by sequence by clinical group
Utilization by discipline for 1st 30-day periods
Utilization by discipline for subsequent 30-day periods

SLIDE 10

PDGM Data Gathering

10

Projected LUPAs
Broken down for 1st 30 days vs subsequent 30 days.
Top Diagnosis by each Clinical Group
Benchmarks Comparison/Goals from Clinical Operations:
Functional Assessment
Comorbidities
Care Plans/Pathways
Program Development (Joints, Cardiac, Wound, IV Therapy, Telehealth,

etc.)

Productivity
Staffing (LPN, COTA, PTA)
Caseloads
Sales & Marketing Goals
Institutional vs Community
Joint and other program development

SLIDE 11

Establish a Baseline for Medicare

11

CMS is projecting impact analysis based on 2018 claims data,

this includes the basis for the behavioral adjustment.

Basis - 2018 Claims Data from Medicare
Medicare discarded roughly 15% of claims because there was no matching OASIS.
Medicare made assumptions on the functional assessment
Medicare assumes that Questionable Encounters with a billable secondary diagnosis

will be used to determine reimbursement.

Utilize the 2018 data as the base then use current state Medicare metrics to

determine overall impact!

SLIDE 12

Establish a Baseline for Medicare

12

Total Revenue Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM Revenue 1,717,339 $ 2,299,525 $ 2,480,486 $ 2,511,951 $ 2,519,811 $ 2,537,786 $ 2,550,913 $ 2,564,937 $ 2,574,486 $ 2,583,864 $ 2,586,489 $ 2,587,772 $ 29,515,359 $ Behavioral Adjustment 137,558.83 $ 184,191.97 $ 198,686.95 $ 201,207.27 $ 201,836.85 $ 203,276.65 $ 204,328.14 $ 205,451.46 $ 206,216.35 $ 206,967.50 $ 207,177.76 $ 207,280.54 $ 2,364,180 $ PPS Revenue 709,900 $ 154,100 $ 864,000 $ Total Revenue 2,289,680 $ 2,269,433 $ 2,281,799 $ 2,310,744 $ 2,317,974 $ 2,334,509 $ 2,346,585 $ 2,359,486 $ 2,368,270 $ 2,376,896 $ 2,379,311 $ 2,380,492 $ 28,015,179 $

SLIDE 13

Why Sequence Periods by Clinical Group?

13

Each Clinical Grouping has its own reimbursement rate.
Ability to review detail of each Clinical Group (functional assessment, LUPAs,

comorbidities, admission source).

Track visit utilization by each Clinical Group (matching cost with revenue).
What is the financial impact on decisions regarding:
Market Expansion
Specialty Program Development
ACO, Joint and other initiatives
Care Pathway/Plan changes
Case Management
Plan of Care Development

SLIDE 14

Why Sequence Periods by Clinical Group?

14

Sequencing of episodes demonstrated impact of length of stay and visit

utilization:

30-day vs 60 day
Significant reimbursement difference between 1st 30 and 2nd 30 day
Will my agency adjusted it’s visit utilization around:
Therapy Utilization
2nd 30-day LUPA Thresholds
Specialty program and initiatives
Remember that a 1st 30 day early institutional is the first 30-day

admission period only! Recert OASIS have a significantly different reimbursement.

SLIDE 15

Why Sequence Periods by Clinical Group?

15

Clinical Grouping Periods per Admission Episodes w/ One 30 Day Period Periods per Admission Episodes w/ One 30 Day Period Behavioral Health Care 1.80 39.90% 1.38 19.10% Complex Nursing Interventions 4.67 15.70% 1.55 13.50% MMTA- Surgical Aftercare 0.75 57.00% 0.54 46.60% MMTA- Cardiac/Circulator 1.56 42.10% 1.30 22.30% MMTA- Endocrine 1.68 39.60% 1.43 16.30% MMTA- GI/GU 1.41 45.60% 1.05 30.90% MMTA- Infectious Disease 1.61 42.80% 0.71 31.00% MMTA- Other 1.44 44.10% 0.80 19.30% MMTA- Respiratory 1.17 48.50% 0.72 28.20% Musculoskeletal Rehabilitation 0.75 60.10% 0.56 42.70% Neuro/Stroke Rehabilitation 1.37 41.50% 0.77 24.90% Wound 2.68 28.80% 0.83 22.80% Questionable Encounters 1.20 49.60% 0.73 29.70% New York National

SLIDE 16

Why Sequence Periods by Clinical Group?

16 Clinical Group 1 2 3 4 2nd 30 Day Variance Recert Variance Behavioral Health Care $2,198 $1,692 $1,716 $1,621 $506 $482 Complex Nursing Interventions $2,059 $1,714 $1,681 $1,625 $345 $378 MMTA- Surgical Aftercare $2,463 $1,793 $2,101 $1,905 $670 $362 MMTA- Cardiac/Circulator $2,455 $1,878 $2,102 $1,964 $577 $353 MMTA- Endocrine $2,465 $1,867 $2,095 $2,040 $598 $370 MMTA- GI/GU $2,414 $1,847 $2,006 $1,916 $567 $408 MMTA- Infectious Disease $2,320 $1,804 $1,894 $1,755 $516 $426 MMTA- Other $2,367 $1,795 $1,977 $1,931 $572 $390 MMTA- Respiratory $2,401 $1,783 $2,056 $1,891 $618 $345 Musculoskeletal Rehabilitation $2,535 $1,842 $2,041 $1,876 $693 $494 Neuro/Stroke Rehabilitation $2,626 $2,014 $2,179 $2,035 $612 $447 Wound $2,638 $2,127 $2,218 $2,142 $511 $420 Questionable Encounters $2,313 $1,739 $1,895 $1,733 $574 $418 New York State Benchmarks Reimbursement per Period

SLIDE 17

Sequence of Periods by Clinical Group

17

Clinical Group 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Behavioral Health Care 47 18 8 4 4 2 2 1 Complex Nursing Interventions 124 83 70 66 58 55 49 40 37 31 22 19 2 1 MMTA- Surgical Aftercare 833 270 89 54 21 13 12 10 6 5 5 5 MMTA- Cardiac/Circulator 1,552 881 440 285 158 102 67 52 36 27 19 13 2 MMTA- Endocrine 148 80 36 22 14 6 2 3 3 1 MMTA- GI/GU 244 107 44 22 12 11 5 2 1 1 1 MMTA- Infectious Disease 249 142 77 35 19 11 8 3 4 2 MMTA- Other 195 103 39 18 8 9 5 4 3 2 2 2 MMTA- Respiratory 743 358 149 93 51 28 17 9 7 6 2 Musculoskeletal Rehabilitation 1,593 493 145 84 61 36 20 10 5 3 Neuro/Stroke Rehabilitation 552 271 123 76 47 22 8 6 3 3 5 3 1 1 Wound 344 239 166 135 77 64 48 40 26 23 11 5 2 Questionable Encounters 1,177 479 214 113 84 43 34 22 10 8 7 3 Total 7,801 3,524 1,600 1,007 614 402 277 202 141 112 74 50 7 2

Periods

SLIDE 18

Reimbursement by Period Sequence by Clinical Group

18

Clinical Group 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Behavioral Health Care 96,220 $ 32,599 $ 11,834 $ 6,821 $ 8,540 $ 3,483 $ 3,622 $ 154 $ Complex Nursing Interventions 229,281 $ 116,069 $ 93,640 $ 92,103 $ 75,841 $ 63,368 $ 47,112 $ 50,020 $ 40,126 $ 38,756 $ 25,756 $ 20,312 $ 1,706 $ 154 $ MMTA- Surgical Aftercare 1,761,918 $ 314,664 $ 158,230 $ 82,064 $ 38,662 $ 19,271 $ 23,012 $ 13,704 $ 9,548 $ 6,766 $ 11,508 $ 10,156 $ MMTA- Cardiac/Circulator 3,463,000 $ 1,322,067 $ 795,733 $ 434,767 $ 265,173 $ 146,651 $ 116,589 $ 78,839 $ 57,683 $ 37,949 $ 31,828 $ 23,691 $ 3,752 $ MMTA- Endocrine 357,532 $ 109,890 $ 64,586 $ 33,527 $ 25,289 $ 13,833 $ 2,697 $ 7,580 $ 2,624 $ 307 $ MMTA- GI/GU 501,596 $ 134,013 $ 75,317 $ 31,470 $ 20,576 $ 18,698 $ 6,400 $ 3,121 $ 1,551 $ 1,551 $ 1,551 $ MMTA- Infectious Disease 539,209 $ 204,745 $ 115,116 $ 42,526 $ 31,764 $ 14,906 $ 11,696 $ 3,432 $ 6,224 $ 2,397 $ MMTA- Other 432,542 $ 139,121 $ 66,217 $ 31,001 $ 20,250 $ 16,327 $ 8,402 $ 8,060 $ 6,598 $ 3,513 $ 3,581 $ 3,581 $ MMTA- Respiratory 1,609,914 $ 480,797 $ 263,323 $ 135,693 $ 83,668 $ 42,230 $ 26,107 $ 14,487 $ 16,458 $ 9,954 $ 5,806 $ Musculoskeletal Rehabilitation 3,760,966 $ 787,299 $ 283,608 $ 154,490 $ 118,814 $ 55,538 $ 35,084 $ 18,235 $ 11,345 $ 3,677 $ Neuro/Stroke Rehabilitation 1,402,104 $ 496,160 $ 263,829 $ 131,852 $ 97,133 $ 31,831 $ 15,461 $ 12,946 $ 6,557 $ 6,295 $ 12,122 $ 4,528 $ 1,648 $ 1,648 $ Wound 886,332 $ 432,759 $ 354,570 $ 252,438 $ 162,324 $ 113,290 $ 94,824 $ 72,075 $ 47,140 $ 44,603 $ 17,854 $ 9,636 $ 4,205 $ Questionable Encounters 2,526,423 $ 701,630 $ 375,872 $ 173,600 $ 159,307 $ 55,787 $ 57,598 $ 35,414 $ 16,042 $ 10,988 $ 11,989 $ 4,188 $ Total 17,567,038 $ 5,271,813 $ 2,921,876 $ 1,602,352 $ 1,107,338 $ 595,211 $ 448,604 $ 318,067 $ 221,897 $ 166,756 $ 121,995 $ 76,093 $ 11,310 $ 1,802 $ Period

SLIDE 19

Visits by Discipline by Period Sequence by Clinical Group

19

Wound Care

Period Sequence 30 Day PDGM Periods PDGM Reimbursement SN Visits PT Visits OT Visits ST Visits HHA Visits MSW Visits 1 344 $886,332 7.6 2.7 0.9 0.1 0.3 0.1 2 239 $432,759 5.7 1.4 0.4 0.1 0.4 0.0 3 166 $354,570 6.7 1.5 0.5 0.1 0.6 0.0 4 135 $252,438 6.0 1.1 0.2 0.1 0.5 0.0 5 77 $162,324 7.6 0.9 0.4 0.0 0.6 0.0 6 64 $113,290 7.2 0.5 0.1 0.0 0.8 0.0 7 48 $94,824 7.5 1.3 0.2 0.0 1.1 0.1 8 40 $72,075 6.7 0.3 0.0 0.0 0.9 0.0 9 26 $47,140 7.4 0.3 0.0 0.0 1.4 0.0 10 23 $44,603 6.8 0.1 0.1 0.0 1.0 0.0 11 11 $17,854 7.6 0.0 0.0 0.0 0.0 0.0 12 5 $9,636 8.2 0.0 0.0 0.0 0.0 0.0 13 2 $4,205 5.0 0.0 0.0 0.0 1.0 0.0 Wound

SLIDE 20

Visits by Discipline by Period Sequence by Clinical Group

20

Musculoskeletal Rehab

Period Sequence 30 Day PDGM Periods PDGM Reimbursement SN Visits PT Visits OT Visits ST Visits HHA Visits MSW Visits 1 1593 $3,760,966 3.4 5.8 1.3 0.0 0.2 0.1 2 493 $787,299 2.5 3.2 0.8 0.0 0.3 0.1 3 145 $283,608 3.9 4.3 1.2 0.1 0.5 0.1 4 84 $154,490 3.7 3.2 1.0 0.1 0.4 0.1 5 61 $118,814 4.3 4.4 1.2 0.1 0.6 0.1 6 36 $55,538 3.1 2.8 0.7 0.0 0.9 0.1 7 20 $35,084 4.3 3.1 0.9 0.2 1.1 0.1 8 10 $18,235 4.6 2.5 0.4 0.0 1.2 0.0 9 5 $11,345 5.0 5.8 2.6 0.8 0.0 0.0 10 3 $3,677 4.0 4.3 0.0 0.0 0.0 0.0 Musculoskeletal Rehab

SLIDE 21

Budget Assumptions

21

Overall change in Medicare admissions
Exclude recert and resumption of care episodes.
Questionable encounter realization percentage
What percentage of the questionable encounters will be

classified into an acceptable clinical group based on primary diagnosis and qualify as billable periods?

Change in admission distribution by clinical group
Adjustments to number of subsequent periods per

admission by clinical group (Length of Stay)

Adjustments to the utilization per period by discipline by

clinical group for 1st 30-day periods and subsequent periods

SLIDE 22

Building the Budget - Volume

22

Medicare Admissions
Start with a baseline
What are your marketing efforts?
Do you expect overall growth in Medicare patients based on these

efforts?

Determine your monthly admissions

Adjustment Adjusted Medicare Admissions (SOC Only) 7,801 0% 7,801 Adjustment Adjusted Medicare Admissions (SOC Only) 7,801 5% 8,191

Monthly Admissions Month 1 Month 2 Month 3 Month 4 Medicare Admissions 1 683 683 683 683

SLIDE 23

Building the Budget – Questionable Encounters

23

Medicare Admissions
Realization of your Questionable Encounters
Allocation of your Questionable Encounters

QE Realization Percentage Base Line % Allocated Questionable Encounters 1,236 99% 1,223 Clinical Grouping Admission % Baseline Admission QE Allocation Clinical Group 0.6% 49 9 Behavioral Health Care 1.6% 130 23 Complex Nursing Interventions 10.7% 875 154 MMTA- Surgical Aftercare 19.9% 1,630 287 MMTA- Cardiac/Circulator 1.9% 155 27 MMTA- Endocrine 3.1% 256 45 MMTA- GI/GU 3.2% 261 46 MMTA- Infectious Disease 2.5% 205 36 MMTA- Other 9.5% 780 137 MMTA- Respiratory 20.4% 1,673 294 Musculoskeletal Rehabilitation 7.1% 580 102 Neuro/Stroke Rehabilitation 4.4% 361 64 Wound 15.1% 1,236 12 Questionable Encounters 100.0% 8,191 1,236

SLIDE 24

Building the Budget – Questionable Encounters

24

How do I determine my Questionable Encounter Realization?
Perform clinical chart audit to determine that the patient can be

moved to a billable Clinical Group based on the secondary diagnosis and the care provided.

For those that cannot be moved based on existing documentation

begin to review the data by:

Clinician
Intake/Liaison
Referral Source
Provide additional education to internal and external stakeholders
n Questionable Encounters.
Determine if Questionable Encounters will have an impact on

volume.

SLIDE 25

Description PPS Episodes PDGM Periods % of Total PDGM Periods PPS Reimbursement Muscle weakness (generalized) 2,926 4,388 1.90% $10,228,733 Other abnormalities of gait and mobility 1,001 1,495 0.60% $3,363,763 Unsteadiness on feet 882 1,396 0.60% $3,100,495 Repeated falls 769 1,100 0.50% $2,532,404 Unspecified osteoarthritis, unspecified site 660 1,053 0.40% $2,469,279 Total $21,694,674

Building the Budget – Questionable Encounters Top 5 New York Questionable Encounters

SLIDE 26

Building the Budget Clinical Grouping Distribution

26

Will my distribution by Clinical Grouping be adjusted?

Clinical Grouping Admission % Baseline Admission QE Allocation Other Adjustment New Admissions Clinical Group 0.6% 49 9 58 Behavioral Health Care 1.6% 130 23 153 Complex Nursing Interventions 10.7% 875 154 1,029 MMTA- Surgical Aftercare 19.9% 1,630 287 1,916 MMTA- Cardiac/Circulator 1.9% 155 27 50 233 MMTA- Endocrine 3.1% 256 45 50 351 MMTA- GI/GU 3.2% 261 46 307 MMTA- Infectious Disease 2.5% 205 36 241 MMTA- Other 9.5% 780 137 (100) 817 MMTA- Respiratory 20.4% 1,673 294 1,967 Musculoskeletal Rehabilitation 7.1% 580 102 682 Neuro/Stroke Rehabilitation 4.4% 361 64 425 Wound 15.1% 1,236 12 12 Questionable Encounters 100.0% 8,191 1,236 8,191

SLIDE 27

Building the Budget Clinical Grouping Distribution

Clinical Grouping Periods Distribution Periods Distribution Behavioral Health Care 2802 1.19% 186,032 2.04% Complex Nursing Interventions 4546 1.93% 169,787 1.86% MMTA- Surgical Aftercare 13863 5.88% 327,182 3.58% MMTA- Cardiac/Circulator 36,456 15.46% 1,466,008 16.06% MMTA- Endocrine 5663 2.40% 406,198 4.45% MMTA- GI/GU 11037 4.68% 363,700 3.98% MMTA- Infectious Disease 12797 5.43% 382,054 4.18% MMTA- Other 14636 6.21% 679,631 7.44% MMTA- Respiratory 16686 7.08% 711,651 7.79% Musculoskeletal Rehabilitation 39061 16.57% 1,556,357 17.05% Neuro/Stroke Rehabilitation 19231 8.16% 783,656 8.58% Wound 31071 13.18% 866,903 9.49% Questionable Encounters 27911 11.84% 1,230,645 13.48% Total 235,760 9,130,322 New York National

SLIDE 28

Building the Budget Clinical Grouping Distribution

28

Will my distribution by Clinical Grouping be adjusted?
New referral source with different distribution of patients going to Home

Care?

Development of specialty programs.
Goals and objectives around rehospitalization rates for current referral

sources.

CHF
COPD
Rehab/Joints
Wounds
Review of primary diagnosis:
Coding Audit of MMTA Other!

SLIDE 29

Building the Budget Length of Stay

29

Periods per Admission
How might your ALOS of change?
Do you expect the number of subsequent periods per admission to

change based any organizational changes?

Clinical Grouping Baseline Subsequent Periods Adjustment of Periods Avg # of Subsequent Periods Clinical Group 0.83 0.83 Behavioral Health Care 4.30 4.30 Complex Nursing Interventions 0.59 0.59 MMTA- Surgical Aftercare 1.34 1.34 MMTA- Cardiac/Circulator 1.13 1.13 MMTA- Endocrine 0.84 0.84 MMTA- GI/GU 1.21 1.21 MMTA- Infectious Disease 1.00 1.00 MMTA- Other 0.97 0.97 MMTA- Respiratory 0.54 0.54 Musculoskeletal Rehabilitation 1.03 1.03 Neuro/Stroke Rehabilitation 2.43 2.43 Wound 0.86 0.86

SLIDE 30

Building the Budget Length of Stay

30

Evaluate visit frequencies and discharge processes.
Review rehospitalization rates by key diagnosis in each Clinical Group.
Adjust LOS based on operational goals for improved quality and changes in clinical

management.

Clinical Group 1 2 % w 2nd Period Goal Variance Additonal Periods

Behavioral Health Care 47 18 38% 50% 12% 6 Complex Nursing Interventions 124 83 67% 80% 13% 16 MMTA- Surgical Aftercare 833 270 32% 32%

MMTA- Cardiac/Circulator

1,552 881 57% 80% 23% 361 MMTA- Endocrine 148 80 54% 80% 26% 38 MMTA- GI/GU 244 107 44% 60% 16% 39 MMTA- Infectious Disease 249 142 57% 60% 3% 7 MMTA- Other 195 103 53% 60% 7% 14 MMTA- Respiratory 743 358 48% 60% 12% 88 Musculoskeletal Rehabilitation 1,593 493 31% 31% 0%

Neuro/Stroke Rehabilitation

552 271 49% 49% 0%

Wound

344 239 69% 77% 8% 27 Total 7,801 3,524 45% 53% 8% 596

Periods Length of Stay Analysis

SLIDE 31

Building the Budget Length of Stay

31

Periods per Admission - Adjusted

Clinical Grouping Baseline Subsequent Periods Adjustment of Periods Avg # of Subsequent Periods Clinical Group 0.83 0.12 0.95 Behavioral Health Care 4.30 0.13 4.43 Complex Nursing Interventions 0.59

0.59

MMTA- Surgical Aftercare 1.34 0.23 1.57 MMTA- Cardiac/Circulator 1.13 0.26 1.39 MMTA- Endocrine 0.84 0.16 1.01 MMTA- GI/GU 1.21 0.03 1.24 MMTA- Infectious Disease 1.00 0.07 1.07 MMTA- Other 0.97 0.12 1.09 MMTA- Respiratory 0.54

0.54

Musculoskeletal Rehabilitation 1.03

1.03

Neuro/Stroke Rehabilitation 2.43 0.08 2.51 Wound 0.86 0.86

SLIDE 32

Building the Budget – Revenue Per Period

32

Revenue per Period
How might your revenue per period change?
Functional, LUPA, Comorbidities

Clinical Grouping 1st 30 Day Subsequent 30 Day Clinical Group 2,047 $ 1,719 $ Behavioral Health Care 1,849 $ 1,248 $ Complex Nursing Interventions 2,115 $ 1,403 $ MMTA- Surgical Aftercare 2,231 $ 1,592 $ MMTA- Cardiac/Circulator 2,416 $ 1,559 $ MMTA- Endocrine 2,056 $ 1,428 $ MMTA- GI/GU 2,165 $ 1,438 $ MMTA- Infectious Disease 2,218 $ 1,573 $ MMTA- Other 2,167 $ 1,498 $ MMTA- Respiratory 2,361 $ 1,713 $ Musculoskeletal Rehabilitation 2,540 $ 1,902 $ Neuro/Stroke Rehabilitation 2,577 $ 1,921 $ Wound 2,146 $ 1,576 $

SLIDE 33

Building the Budget – Revenue Per Period

33

Revenue per Period- Functional Assessment
Coding Audit for Opportunity
Ongoing Quality Review & Therapy Assessment
Functional Assessment:
National –High 33%, Medium -33%, Low- 33%
NY State High – 38%, Medium 33%, Low 29%

SLIDE 34

Building the Budget – Revenue Per Period

34

Clinical Grouping High Medium Low High Medium Low High Variance Periods Reimbursement Impact Medium to High Clinical Group 2,400 $ 2,200 $ 2,050 $

35% 30% 35% 3% 108 647.70 $

Behavioral Health Care 2,000 $ 1,800 $ 1,650 $

28% 39% 33% 10% 627 12,538.40 $

Complex Nursing Interventions 2,115 $ 1,915 $ 1,765 $

34% 35% 31% 4% 1582 12,652.25 $

MMTA- Surgical Aftercare 2,231 $ 2,031 $ 1,881 $

22% 56% 22% 16% 4591 146,906.05 $

MMTA- Cardiac/Circulator 2,416 $ 2,216 $ 2,066 $

21% 39% 40% 17% 530 18,008.27 $

MMTA- Endocrine 2,056 $ 1,856 $ 1,706 $

33% 29% 38% 5% 679 6,790.24 $

MMTA- GI/GU 2,165 $ 1,965 $ 1,815 $

35% 32% 33% 3% 660 3,962.77 $

MMTA- Infectious Disease 2,218 $ 2,018 $ 1,868 $

33% 38% 29% 5% 475 4,752.18 $

MMTA- Other 2,200 $ 2,000 $ 1,850 $

28% 41% 31% 10% 1636 32,716.54 $

MMTA- Respiratory 2,500 $ 2,300 $ 2,150 $

32% 40% 28% 6% 2954 35,450.33 $

Musculoskeletal Rehabilitation 2,700 $ 2,500 $ 2,350 $

38% 27% 35% 0% 1324

$

Neuro/Stroke Rehabilitation 2,650 $ 2,450 $ 2,300 $

35% 32% 33% 3% 1304 7,823.53 $

Wound 2,400 $ 2,200 $ 2,050 $

34% 34% 32% 4% 22 176.26 $

SLIDE 35

Building the Budget – Revenue Per Period

35

Revenue per Period – LUPA Management
LUPA Management
National 1st 30 Day – 3%
National 2nd 30 Day – 5%
NY State 1st 30 Day – 5%
NY State 2nd 30 Day – 7%

SLIDE 36

Building the Budget – Revenue Per Period

36

Revenue per Period – LUPA Management

Clinical Group 1st 2nd 1st 2nd 1st 2nd

Behavioral Health Care 750.00 $ 550.00 $ 2,201.28 $ 1,650.25 $ 1,451.28 $ 1,100.25 $ Complex Nursing Interventions 840.00 $ 720.00 $ 2,087.84 $ 1,681.80 $ 1,247.84 $ 961.80 $ MMTA- Cardiac/Circulator 900.00 $ 710.00 $ 2,466.54 $ 1,900.30 $ 1,566.54 $ 1,190.30 $ MMTA- Endocrine 810.00 $ 440.00 $ 2,504.82 $ 2,034.08 $ 1,694.82 $ 1,594.08 $ MMTA- GI/GU 830.00 $ 525.00 $ 2,469.85 $ 2,012.00 $ 1,639.85 $ 1,487.00 $ MMTA- Infectious Disease/Neoplasms/Blood-forming Diseases 900.00 $ 425.00 $ 2,411.62 $ 1,922.65 $ 1,511.62 $ 1,497.65 $ MMTA- Other 725.00 $ 300.00 $ 2,362.76 $ 1,865.72 $ 1,637.76 $ 1,565.72 $ MMTA- Respiratory 840.00 $ 200.00 $ 2,336.12 $ 1,881.38 $ 1,496.12 $ 1,681.38 $ MMTA- Surgical Aftercare 960.00 $ 400.00 $ 2,406.73 $ 1,919.25 $ 1,446.73 $ 1,519.25 $ Musculoskeletal Rehabilitation 900.00 $ 810.00 $ 2,640.00 $ 1,999.17 $ 1,740.00 $ 1,189.17 $ Neuro/Stroke Rehabilitation 900.00 $ 700.00 $ 2,673.21 $ 2,138.29 $ 1,773.21 $ 1,438.29 $ Questionable Encounters 780.00 $ 650.00 $ 2,753.24 $ 2,289.00 $ 1,973.24 $ 1,639.00 $ Wound 660.00 $ 450.00 $ 2,391.42 $ 1,800.12 $ 1,731.42 $ 1,350.12 $

LUPA Rates Full Episode Rates LUPA to Full Variance

SLIDE 37

Building the Budget – Revenue Per Period

37

Revenue per Period – LUPA Management
Review 2nd 30 Day Period for Opportunity
Reviewed Missed Visits
20% LUPA on 2nd 30 Day/Goal 10%
No reduction in LUPAs in Therapy Groupings

Clinical Group LUPA LUPA Adjusment Reimbursement 2nd 30 Day Target 10% Impact

Behavioral Health Care 5 2

2,585.59 $

Complex Nursing Interventions 20 10

9,541.10 $

MMTA- Cardiac/Circulator 54 27

32,138.06 $

MMTA- Endocrine 248 124

197,921.20 $

MMTA- GI/GU 24 12

17,606.08 $

MMTA- Infectious Disease/Neoplasms/Blood-forming Diseases 29 15

21,925.53 $

MMTA- Other 30 15

23,391.81 $

MMTA- Respiratory 23 12

19,672.12 $

MMTA- Surgical Aftercare 89

$

Musculoskeletal Rehabilitation 99

$

Neuro/Stroke Rehabilitation 54

$

Questionable Encounters 53 27

43,526.48 $

Wound 824 412 556,230.09 $

SLIDE 38

Building the Budget – Revenue Per Period

38

Revenue per Period - Comorbidities
Perform Chart Audit – what can we change?
Review EMR functionality of secondary diagnosis to claim.
NY State High – 10%, Low – 36%, No – 54%
National – 8%, Low – 35%, No – 57%

36% Low Target Total Financial Clinical Grouping No Low High No Low High Low Variance Periods Impact

Behavioral Health Care

2,050 $ 2,300 $ 2,600 $

50% 40% 10% 0%

108

$

Complex Nursing Interventions

1,850 $ 2,100 $ 2,400 $

51% 38% 11% 0%

627

$

MMTA- Surgical Aftercare

1,650 $ 1,900 $ 2,200 $

60% 32% 8% 4%

1582

15,815 $

MMTA- Cardiac/Circulator

1,681 $ 1,931 $ 2,231 $

58% 36% 6% 0%

4591

$

MMTA- Endocrine

2,076 $ 2,326 $ 2,626 $

55% 36% 9% 0%

530

$

MMTA- GI/GU

1,850 $ 2,100 $ 2,400 $

55% 37% 8% 0%

679

$

MMTA- Infectious Disease

1,650 $ 1,900 $ 2,200 $

52% 39% 9% 0%

660

$

MMTA- Other

1,550 $ 1,800 $ 2,100 $

50% 40% 10% 0%

475

$

MMTA- Respiratory

1,650 $ 1,900 $ 2,200 $

54% 35% 11% 1%

1636

4,090 $

Musculoskeletal Rehabilitation

2,250 $ 2,500 $ 2,800 $

75% 22% 3% 14%

2954

103,397 $

Neuro/Stroke Rehabilitation

2,150 $ 2,400 $ 2,700 $

74% 22% 4% 14%

1324

46,341 $

Wound

2,100 $ 2,350 $ 2,650 $

39% 50% 11% 0%

1304

$

Comorbidity Reimbursement Comorbiditiy Distribution

SLIDE 39

Building the Budget – Revenue Per Period

39

Revenue per Period - Comorbidities

36% Low Target Total Financial Clinical Grouping No Low High No Low High Low Variance Periods Impact

Behavioral Health Care

2,050 $ 2,300 $ 2,600 $

50% 40% 10% 0%

108

$

Complex Nursing Interventions

1,850 $ 2,100 $ 2,400 $

51% 38% 11% 0%

627

$

MMTA- Surgical Aftercare

1,650 $ 1,900 $ 2,200 $

60% 32% 8% 4%

1582

15,815 $

MMTA- Cardiac/Circulator

1,681 $ 1,931 $ 2,231 $

58% 36% 6% 0%

4591

$

MMTA- Endocrine

2,076 $ 2,326 $ 2,626 $

55% 36% 9% 0%

530

$

MMTA- GI/GU

1,850 $ 2,100 $ 2,400 $

55% 37% 8% 0%

679

$

MMTA- Infectious Disease

1,650 $ 1,900 $ 2,200 $

52% 39% 9% 0%

660

$

MMTA- Other

1,550 $ 1,800 $ 2,100 $

50% 40% 10% 0%

475

$

MMTA- Respiratory

1,650 $ 1,900 $ 2,200 $

54% 35% 11% 1%

1636

4,090 $

Musculoskeletal Rehabilitation

2,250 $ 2,500 $ 2,800 $

75% 22% 3% 14%

2954

103,397 $

Neuro/Stroke Rehabilitation

2,150 $ 2,400 $ 2,700 $

74% 22% 4% 14%

1324

46,341 $

Wound

2,100 $ 2,350 $ 2,650 $

39% 50% 11% 0%

1304

$

Comorbidity Reimbursement Comorbiditiy Distribution

SLIDE 40

Building the Budget – Revenue Per Period

40

Revenue per Period
How might your revenue per period change?
Adjusted Revenues

Clinical Grouping 1st 30 Day Subsequent 30 Day Clinical Group 2,147 $ 1,744 $ Behavioral Health Care 1,939 $ 1,272 $ Complex Nursing Interventions 2,195 $ 1,426 $ MMTA- Surgical Aftercare 2,301 $ 1,614 $ MMTA- Cardiac/Circulator 2,476 $ 1,580 $ MMTA- Endocrine 2,106 $ 1,448 $ MMTA- GI/GU 2,205 $ 1,457 $ MMTA- Infectious Disease 2,248 $ 1,591 $ MMTA- Other 2,187 $ 1,515 $ MMTA- Respiratory 2,371 $ 1,729 $ Musculoskeletal Rehabilitation 2,560 $ 1,917 $ Neuro/Stroke Rehabilitation 2,607 $ 1,935 $ Wound 2,186 $ 1,589 $ Questionable Encounters

$
$

SLIDE 41

Building the Budget

41

Visit Utilization per Period by Discipline
Break-out Baseline for 1st 30 Day Periods vs. All Subsequent Periods

SLIDE 42

Building the Budget

42

Visit Utilization per Period by Discipline
Break-out Baseline for 1st 30 Day Periods vs. All Subsequent Periods

SN Visits PT Visits OT Visits ST Visits HHA Visits MSW Visits Behavioral Health Care 2.8 2.8 0.7 0.1 0.1 0.1 Complex Nursing Interventions 2.9 0.9 0.3 0.0 0.8 0.0 MMTA- Surgical Aftercare 5.0 1.6 0.4 0.0 0.2 0.0 MMTA- Cardiac/Circulator 4.6 2.1 0.5 0.0 0.2 0.0 MMTA- Endocrine 3.7 2.1 0.5 0.0 0.1 0.1 MMTA- GI/GU 3.6 1.8 0.3 0.0 0.2 0.0 MMTA- Infectious Disease 4.2 1.4 0.3 0.1 0.2 0.0 MMTA- Other 5.7 1.8 0.5 0.0 0.6 0.1 MMTA- Respiratory 4.5 2.2 0.6 0.1 0.4 0.0 Musculoskeletal Rehabilitation 3.1 3.5 0.9 0.1 0.4 0.1 Neuro/Stroke Rehabilitation 2.7 3.4 1.2 0.5 0.4 0.1 Wound 6.5 1.1 0.3 0.1 0.6 0.0 Questionable Encounters 3.0 2.9 0.7 0.1 0.3 0.0 Subsequent 30 Day Period - Baseline Visit Utilization

SLIDE 43

Building the Budget

43

Visit Utilization per Period by Discipline
Do you expect any changes to your utilization?
Based on potential changes in plan of care strategies to improve patient outcomes, reduce

LUPA percentage or as a result of accepting higher acuity patients from marketing efforts.

SN Visits PT Visits OT Visits ST Visits HHA Visits MSW Visits Behavioral Health Care Complex Nursing Interventions MMTA- Surgical Aftercare MMTA- Cardiac/Circulator MMTA- Endocrine MMTA- GI/GU MMTA- Infectious Disease MMTA- Other MMTA- Respiratory Musculoskeletal Rehabilitation Neuro/Stroke Rehabilitation Wound Questionable Encounters 1st 30 Day Period - Adjustments Visit Utilization

SLIDE 44

Building the Budget

44

Visit Utilization per Period by Discipline
Do you expect any changes to your utilization?
Based on potential changes in plan of care strategies to improve patient outcomes, reduce

LUPA percentage or as a result of accepting higher acuity patients from marketing efforts.

SN Visits PT Visits OT Visits ST Visits HHA Visits MSW Visits Behavioral Health Care 1.0 Complex Nursing Interventions MMTA- Surgical Aftercare

0.5

MMTA- Cardiac/Circulator 2.0 0.5 MMTA- Endocrine 0.5 MMTA- GI/GU MMTA- Infectious Disease MMTA- Other MMTA- Respiratory Musculoskeletal Rehabilitation 1.0

0.5

Neuro/Stroke Rehabilitation 2.0 Wound Questionable Encounters Subsequent 30 Day Period - Adjustments Visit Utilization

SLIDE 45

Building the Budget

45

Visit Utilization per Period by Discipline
Adjusted Utilization for 1st 30 Day Periods and All Subsequent Periods

SLIDE 46

Building the Budget

46

Visit Utilization per Period by Discipline
Adjusted Utilization for 1st 30 Day Periods and All Subsequent Periods

SN Visits PT Visits OT Visits ST Visits HHA Visits MSW Visits Behavioral Health Care 3.8 2.8 0.7 0.1 0.1 0.1 Complex Nursing Interventions 2.9 0.9 0.3 0.0 0.8 0.0 MMTA- Surgical Aftercare 5.0 1.1 0.4 0.0 0.2 0.0 MMTA- Cardiac/Circulator 6.6 2.6 0.5 0.0 0.2 0.0 MMTA- Endocrine 3.7 2.6 0.5 0.0 0.1 0.1 MMTA- GI/GU 3.6 1.8 0.3 0.0 0.2 0.0 MMTA- Infectious Disease 4.2 1.4 0.3 0.1 0.2 0.0 MMTA- Other 5.7 1.8 0.5 0.0 0.6 0.1 MMTA- Respiratory 4.5 2.2 0.6 0.1 0.4 0.0 Musculoskeletal Rehabilitation 4.1 3.0 0.9 0.1 0.4 0.1 Neuro/Stroke Rehabilitation 4.7 3.4 1.2 0.5 0.4 0.1 Wound 6.5 1.1 0.3 0.1 0.6 0.0 Questionable Encounters 3.0 2.9 0.7 0.1 0.3 0.0 Subsequent 30 Day Period - Adjustments Visit Utilization

SLIDE 47

Transitional Patients

47

Example of PDGM Carry-over of Patients Admitted prior to Jan 1, 2020 Admit month Payment Method: Dec Jan Feb PPS 1 2 3 4 PDGM Nov Dec Jan Feb 1 2 3 4 60-day cert periods Oct Nov Dec Jan Feb 1 2 3 4 5 6 Sep Oct Nov Dec Jan Feb 1 2 3 4 5 6 Aug Sep Oct Nov Dec Jan Feb 1 2 3 4 5 6 7 8 Jul Aug Sep Oct Nov Dec Jan Feb 1 2 3 4 5 6 7 8 Jun Jul Aug Sep Oct Nov Dec Jan Feb 1 2 3 4 5 6 7 8 9 10

SLIDE 48

PPS Data Gathering

48

Projected Medicare census on 12/31/2019
Medicare daily discharges
Average visits per episode by discipline
Average PPS revenue per episode
PPS average length of stay (ALOS)

Medicare Census 12/31/2019 650 Medicare Daily Discharges 12 SN 5 PT 3 OT 2 ST 0.5 MSW 0.2 HHA 1 PPS Revenue Per Episode 3,000 $ PPS Length of Stay 60 Average Visits Per Episode PPS Assumptions

SLIDE 49

Building the Budget

49

Bridging Medicare PPS to Medicare PDGM
Transition of patient volume of PPS patients recertifying and

becoming PDGM patients

December January February March April May June July August September October November December Behavioral Health Care 5 2 1

Complex Nursing Interventions

13 9 8 7 6 6 5 4 4 3 2 2 MMTA- Surgical Aftercare 88 28 9 6 2 1 1 1 1 1 1 1

MMTA- Cardiac/Circulator

164 109 54 35 20 13 8 6 4 3 2 2 MMTA- Endocrine 20 13 6 4 2 1

MMTA- GI/GU

30 16 6 3 2 2 1

MMTA- Infectious Disease

26 15 8 4 2 1 1

MMTA- Other

21 12 4 2 1 1 1

MMTA- Respiratory

70 38 16 10 5 3 2 1 1 1

Musculoskeletal Rehabilitation

168 52 15 9 6 4 2 1 1

Neuro/Stroke Rehabilitation

58 29 13 8 5 2 1 1 1 Wound 36 26 18 15 8 7 5 4 3 3 1 1 Questionable Encounters 1

Starting PDGM Subsequent Census

Clinical Group

SLIDE 50

Building the Budget

50

PPS Medicare Revenue and Visits by Discipline
Based on projected end of year census and discharges per day

January Census Revenue SN Visits PT Visits OT Vistis ST Visits MSW Visits HHA Visits 1 638 31,900 $ 53 32 21 5 2 11 2 626 31,300 $ 52 31 21 5 2 10 3 614 30,700 $ 51 31 20 5 2 10 4 602 30,100 $ 50 30 20 5 2 10 5 590 29,500 $ 49 30 20 5 2 10 6 578 28,900 $ 48 29 19 5 2 10 7 566 28,300 $ 47 28 19 5 2 9 8 554 27,700 $ 46 28 18 5 2 9 9 542 27,100 $ 45 27 18 5 2 9 10 530 26,500 $ 44 27 18 4 2 9 11 518 25,900 $ 43 26 17 4 2 9 12 506 25,300 $ 42 25 17 4 2 8 13 494 24,700 $ 41 25 16 4 2 8 14 482 24,100 $ 40 24 16 4 2 8 15 470 23,500 $ 39 24 16 4 2 8

SLIDE 51

Building the Budget

51

PPS Medicare Revenue and Visits by Discipline
Based on projected end of year census and discharges per day

16 458 22,900 $ 38 23 15 4 2 8 17 446 22,300 $ 37 22 15 4 1 7 18 434 21,700 $ 36 22 14 4 1 7 19 422 21,100 $ 35 21 14 4 1 7 20 410 20,500 $ 34 21 14 3 1 7 21 398 19,900 $ 33 20 13 3 1 7 22 386 19,300 $ 32 19 13 3 1 6 23 374 18,700 $ 31 19 12 3 1 6 24 362 18,100 $ 30 18 12 3 1 6 25 350 17,500 $ 29 18 12 3 1 6 26 338 16,900 $ 28 17 11 3 1 6 27 326 16,300 $ 27 16 11 3 1 5 28 314 15,700 $ 26 16 10 3 1 5 29 302 15,100 $ 25 15 10 3 1 5 30 290 14,500 $ 24 15 10 2 1 5 31 278 13,900 $ 23 14 9 2 1 5 709,900 $ 1,183 710 473 118 47 237 Total

SLIDE 52

Building the Budget

52

PPS Medicare Revenue and Visits by Discipline
Based on projected end of year census and discharges per day

February Census Revenue SN Visits PT Visits OT Vistis ST Visits MSW Visits HHA Visits 1 168 2,373 $ 9 3 1 1 2 2 162 2,288 $ 9 3 1 1 2 3 156 2,203 $ 9 2 1 1 2 4 150 2,119 $ 8 2 1 1 2 5 144 2,034 $ 8 2 1 1 2 6 138 1,949 $ 8 2 1 2 7 132 1,864 $ 7 2 1 2 8 126 1,780 $ 7 2 1 1 9 120 1,695 $ 7 2 1 1 10 114 1,610 $ 6 2 1 1 11 108 1,525 $ 6 2 1 1 12 102 1,441 $ 6 2 1 1 13 96 1,356 $ 5 1 1 1 14 90 1,271 $ 5 1 1 1 15 84 1,186 $ 5 1 1 1

SLIDE 53

Building the Budget

53

PPS Medicare Revenue and Visits by Discipline
Based on projected end of year census and discharges per day

February Census Revenue SN Visits PT Visits OT Vistis ST Visits MSW Visits HHA Visits 16 86 4,300 $ 7 4 3 1 1 17 74 3,700 $ 6 4 2 1 1 18 62 3,100 $ 5 3 2 1 1 19 50 2,500 $ 4 3 2 1 20 38 1,900 $ 3 2 1 1 21 26 1,300 $ 2 1 1 22 14 700 $ 1 1 23 2 100 $ 24

$
25
$
26
$
27
$
28
$
29
$
154,100

$ 257 154 103 26 10 51 Total

SLIDE 54

Building the Budget

54

Medicare PDGM Admissions
Reflects 5% growth in total Medicare admissions
Clinical Group Distribution Changes

Admissions Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 5 5 5 5 5 5 5 5 5 5 5 5 Complex Nursing Interventions 13 13 13 13 13 13 13 13 13 13 13 13 MMTA- Surgical Aftercare 86 86 86 86 86 86 86 86 86 86 86 86 MMTA- Cardiac/Circulator 160 160 160 160 160 160 160 160 160 160 160 160 MMTA- Endocrine 19 19 19 19 19 19 19 19 19 19 19 19 MMTA- GI/GU 29 29 29 29 29 29 29 29 29 29 29 29 MMTA- Infectious Disease 26 26 26 26 26 26 26 26 26 26 26 26 MMTA- Other 20 20 20 20 20 20 20 20 20 20 20 20 MMTA- Respiratory 68 68 68 68 68 68 68 68 68 68 68 68 Musculoskeletal Rehabilitation 164 164 164 164 164 164 164 164 164 164 164 164 Neuro/Stroke Rehabilitation 57 57 57 57 57 57 57 57 57 57 57 57 Wound 35 35 35 35 35 35 35 35 35 35 35 35 Questionable Encounters 1 1 1 1 1 1 1 1 1 1 1 1 Total 683 683 683 683 683 683 683 683 683 683 683 683

SLIDE 55

Building the Budget

55

Medicare PDGM Subsequent Periods
Subsequent PDGM periods for PDGM admission (includes 5% growth)
Changes in Length of Stay

Subsequent Periods Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 1 4 4 4 5 5 5 5 5 5 5 5 Complex Nursing Interventions 1 18 25 31 37 42 46 50 53 56 57 58 MMTA- Surgical Aftercare 16 42 49 49 48 48 49 50 50 50 51 51 MMTA- Cardiac/Circulator 46 184 229 237 238 241 244 248 250 252 253 253 MMTA- Endocrine 6 22 26 27 27 27 26 27 27 27 27 27 MMTA- GI/GU 8 25 30 29 29 30 30 29 29 30 30 29 MMTA- Infectious Disease 7 27 33 32 31 32 32 32 32 32 32 32 MMTA- Other 6 18 21 20 20 21 21 21 21 21 22 22 MMTA- Respiratory 19 60 73 74 74 74 74 74 74 75 74 74 Musculoskeletal Rehabilitation 30 75 86 87 89 89 89 89 89 88 88 88 Neuro/Stroke Rehabilitation 14 47 57 59 59 58 57 58 58 58 59 59 Wound 7 49 65 74 76 81 84 87 88 90 89 89 Questionable Encounters 1 1 1 1 1 1 1 1 1 1 1 Total

SLIDE 56

Building the Budget

56

Total Medicare PDGM Periods

Total Periods Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 6 8 9 9 9 9 10 10 9 9 9 9 Complex Nursing Interventions 14 30 38 44 49 55 59 62 66 68 70 71 MMTA- Surgical Aftercare 101 128 135 135 133 134 135 135 136 136 136 137 MMTA- Cardiac/Circulator 206 344 389 397 398 401 404 408 410 411 412 412 MMTA- Endocrine 26 41 46 46 47 46 46 46 47 46 46 46 MMTA- GI/GU 37 54 59 58 58 59 59 59 59 59 59 59 MMTA- Infectious Disease 33 53 59 57 57 57 57 57 58 58 57 57 MMTA- Other 26 38 41 40 40 41 41 41 41 41 42 42 MMTA- Respiratory 87 128 141 142 142 142 142 142 142 143 142 142 Musculoskeletal Rehabilitation 194 239 250 251 253 253 253 253 252 252 252 252 Neuro/Stroke Rehabilitation 70 104 114 116 116 115 114 114 114 115 116 116 Wound 43 84 101 110 111 116 119 122 123 125 125 125 Questionable Encounters 1 2 2 2 2 2 2 2 2 2 2 2 Total 845 1254 1383 1408 1416 1430 1441 1452 1459 1466 1469 1470

SLIDE 57

Building the Budget

57

Medicare PDGM Admissions Revenue
Factors in Functional Level, Comorbidities, & LUPA Management

Admissions Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ 10,384 $ Complex Nursing Interventions 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ 24,739 $ MMTA- Surgical Aftercare 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ 188,144 $ MMTA- Cardiac/Circulator 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ 367,494 $ MMTA- Endocrine 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ 48,017 $ MMTA- GI/GU 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ 61,639 $ MMTA- Infectious Disease 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ 56,505 $ MMTA- Other 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ 45,107 $ MMTA- Respiratory 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ 148,953 $ Musculoskeletal Rehabilitation 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ 388,613 $ Neuro/Stroke Rehabilitation 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ 145,401 $ Wound 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ 92,258 $ Questionable Encounters 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $ 2,252 $

SLIDE 58

Building the Budget

58

Medicare PDGM Subsequent Revenue
Factors in Functional Level, Comorbidities, & LUPA Management

Subsequent Periods Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 1,745 $ 6,142 $ 7,392 $ 7,371 $ 7,997 $ 7,986 $ 8,299 $ 8,197 $ 7,987 $ 7,987 $ 7,987 $ 7,987 $ Complex Nursing Interventions 1,787 $ 22,374 $ 31,725 $ 39,897 $ 46,546 $ 53,417 $ 58,999 $ 63,083 $ 67,527 $ 70,683 $ 72,340 $ 74,121 $ MMTA- Surgical Aftercare 22,390 $ 60,396 $ 70,554 $ 70,475 $ 67,927 $ 68,548 $ 69,993 $ 70,827 $ 71,023 $ 71,606 $ 72,340 $ 72,659 $ MMTA- Cardiac/Circulator 74,489 $ 296,774 $ 369,399 $ 383,220 $ 383,894 $ 389,619 $ 394,412 $ 400,193 $ 403,250 $ 406,036 $ 407,632 $ 408,036 $ MMTA- Endocrine 10,008 $ 34,276 $ 41,692 $ 42,637 $ 43,112 $ 42,050 $ 41,640 $ 42,665 $ 43,179 $ 42,786 $ 42,525 $ 42,525 $ MMTA- GI/GU 11,798 $ 36,340 $ 43,022 $ 41,803 $ 42,054 $ 43,457 $ 42,888 $ 42,555 $ 42,550 $ 42,757 $ 42,853 $ 42,641 $ MMTA- Infectious Disease 10,551 $ 39,659 $ 48,364 $ 45,936 $ 45,740 $ 45,946 $ 46,331 $ 46,078 $ 46,702 $ 46,545 $ 46,230 $ 46,230 $ MMTA- Other 9,786 $ 28,788 $ 33,633 $ 32,063 $ 31,763 $ 33,141 $ 33,204 $ 33,630 $ 33,882 $ 34,052 $ 34,403 $ 34,564 $ MMTA- Respiratory 28,445 $ 91,432 $ 110,200 $ 112,406 $ 111,814 $ 111,628 $ 111,883 $ 111,848 $ 112,540 $ 112,997 $ 112,511 $ 112,191 $ Musculoskeletal Rehabilitation 51,742 $ 129,381 $ 148,775 $ 150,176 $ 154,208 $ 154,372 $ 153,962 $ 153,392 $ 153,159 $ 153,013 $ 152,466 $ 152,466 $ Neuro/Stroke Rehabilitation 26,102 $ 90,164 $ 109,893 $ 112,582 $ 113,578 $ 111,512 $ 110,066 $ 110,556 $ 110,541 $ 111,325 $ 112,523 $ 112,517 $ Wound 14,392 $ 94,050 $ 126,279 $ 143,985 $ 146,800 $ 156,244 $ 162,251 $ 167,938 $ 170,149 $ 173,519 $ 172,889 $ 172,472 $ Questionable Encounters 322 $ 1,115 $ 1,344 $ 1,338 $ 1,386 $ 1,381 $ 1,407 $ 1,413 $ 1,408 $ 1,416 $ 1,422 $ 1,418 $

SLIDE 59

Building the Budget

59

Medicare Total PDGM Revenue

Total Revenue Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 12,129 $ 16,526 $ 17,776 $ 17,755 $ 18,381 $ 18,370 $ 18,683 $ 18,581 $ 18,371 $ 18,371 $ 18,371 $ 18,371 $ Complex Nursing Interventions 26,526 $ 47,114 $ 56,464 $ 64,637 $ 71,285 $ 78,156 $ 83,739 $ 87,822 $ 92,266 $ 95,422 $ 97,079 $ 98,860 $ MMTA- Surgical Aftercare 210,534 $ 248,540 $ 258,699 $ 258,619 $ 256,071 $ 256,692 $ 258,137 $ 258,972 $ 259,167 $ 259,751 $ 260,484 $ 260,803 $ MMTA- Cardiac/Circulator 441,983 $ 664,268 $ 736,893 $ 750,714 $ 751,388 $ 757,113 $ 761,905 $ 767,687 $ 770,744 $ 773,530 $ 775,126 $ 775,530 $ MMTA- Endocrine 58,024 $ 82,292 $ 89,708 $ 90,654 $ 91,129 $ 90,067 $ 89,657 $ 90,682 $ 91,196 $ 90,803 $ 90,542 $ 90,542 $ MMTA- GI/GU 73,437 $ 97,979 $ 104,662 $ 103,443 $ 103,694 $ 105,097 $ 104,527 $ 104,194 $ 104,189 $ 104,396 $ 104,493 $ 104,280 $ MMTA- Infectious Disease 67,057 $ 96,164 $ 104,870 $ 102,441 $ 102,245 $ 102,451 $ 102,836 $ 102,583 $ 103,207 $ 103,050 $ 102,735 $ 102,735 $ MMTA- Other 54,894 $ 73,895 $ 78,740 $ 77,170 $ 76,870 $ 78,248 $ 78,311 $ 78,737 $ 78,989 $ 79,160 $ 79,510 $ 79,671 $ MMTA- Respiratory 177,398 $ 240,386 $ 259,154 $ 261,359 $ 260,767 $ 260,581 $ 260,837 $ 260,802 $ 261,493 $ 261,951 $ 261,464 $ 261,145 $ Musculoskeletal Rehabilitation 440,355 $ 517,994 $ 537,388 $ 538,789 $ 542,821 $ 542,985 $ 542,575 $ 542,005 $ 541,772 $ 541,626 $ 541,079 $ 541,079 $ Neuro/Stroke Rehabilitation 171,504 $ 235,565 $ 255,294 $ 257,984 $ 258,979 $ 256,914 $ 255,467 $ 255,957 $ 255,942 $ 256,726 $ 257,924 $ 257,919 $ Wound 106,650 $ 186,309 $ 218,537 $ 236,243 $ 239,059 $ 248,502 $ 254,509 $ 260,197 $ 262,408 $ 265,777 $ 265,148 $ 264,730 $ Questionable Encounters 2,573 $ 3,366 $ 3,596 $ 3,590 $ 3,638 $ 3,633 $ 3,659 $ 3,665 $ 3,660 $ 3,668 $ 3,673 $ 3,670 $

SLIDE 60

Building the Budget

60

Medicare Total Revenue
Combine projected PDGM revenue with PPS revenue for bridge

patients (only realized for first 60 days of 2020)

Total Revenue Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM Revenue 1,843,063 $ 2,510,398 $ 2,721,780 $ 2,763,397 $ 2,776,326 $ 2,798,809 $ 2,814,842 $ 2,831,884 $ 2,843,403 $ 2,854,230 $ 2,857,628 $ 2,859,334 $ 32,475,094 $ Behavioral Adjustment 147,629 $ 201,083 $ 218,015 $ 221,348 $ 222,384 $ 224,185 $ 225,469 $ 226,834 $ 227,757 $ 228,624 $ 228,896 $ 229,033 $ 2,601,255 $ PPS Revenue 709,900 $ 154,100 $ Total Revenue 2,405,334 $ 2,463,415 $ 2,503,766 $ 2,542,049 $ 2,553,942 $ 2,574,625 $ 2,589,373 $ 2,605,050 $ 2,615,646 $ 2,625,606 $ 2,628,732 $ 2,630,302 $ 29,873,839 $

Total Baseline Revenue 29,515,359 $ Behavioral Adjustment 2,601,255 $ Operations Adjustment 2,959,734 $ Total Revenue 29,873,839 $

SLIDE 61

Building the Budget

61

Medicare PDGM Admissions Visits
Skilled Nursing

SLIDE 62

Building the Budget

62

Medicare PDGM Subsequent Period Visits
Skilled Nursing

Subsequent Periods SN Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 4 13 16 16 18 17 18 18 17 17 17 17 Complex Nursing Interventions 4 52 73 92 107 123 136 145 156 163 167 171 MMTA- Surgical Aftercare 78 210 245 245 236 238 243 246 247 249 251 252 MMTA- Cardiac/Circulator 306 1,219 1,517 1,574 1,576 1,600 1,620 1,643 1,656 1,667 1,674 1,676 MMTA- Endocrine 23 80 97 99 100 98 97 99 100 99 99 99 MMTA- GI/GU 29 91 107 104 105 108 107 106 106 106 107 106 MMTA- Infectious Disease 31 116 141 134 133 134 135 134 136 136 135 135 MMTA- Other 35 103 120 114 113 118 119 120 121 122 123 123 MMTA- Respiratory 84 270 325 332 330 330 330 330 332 334 332 331 Musculoskeletal Rehabilitation 123 308 354 358 367 368 367 365 365 364 363 363 Neuro/Stroke Rehabilitation 65 223 272 278 281 276 272 273 273 275 278 278 Wound 48 316 425 484 494 526 546 565 572 584 582 580 Questionable Encounters 1 2 3 3 3 3 3 3 3 3 3 3

SLIDE 63

Building the Budget

63

Medicare Total PDGM Visits
Skilled Nursing

Total PDGM SN Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Behavioral Health Care 22 32 35 35 36 36 37 36 36 36 36 36 Complex Nursing Interventions 63 111 132 151 167 182 195 205 215 222 226 230 MMTA- Surgical Aftercare 404 536 571 571 562 565 570 572 573 575 578 579 MMTA- Cardiac/Circulator 1,192 2,105 2,403 2,460 2,463 2,486 2,506 2,530 2,542 2,554 2,560 2,562 MMTA- Endocrine 118 175 192 194 195 193 192 194 195 194 194 194 MMTA- GI/GU 171 232 249 246 246 250 248 248 248 248 248 248 MMTA- Infectious Disease 163 248 273 266 265 266 267 266 268 268 267 267 MMTA- Other 144 212 229 223 222 227 227 229 230 231 232 232 MMTA- Respiratory 446 632 688 694 693 692 693 693 695 696 695 694 Musculoskeletal Rehabilitation 676 860 907 910 920 920 919 918 917 917 915 915 Neuro/Stroke Rehabilitation 300 458 507 514 516 511 507 508 508 510 513 513 Wound 318 586 695 754 764 795 816 835 842 854 851 850 Questionable Encounters 4 6 6 6 6 6 6 6 6 6 6 6

SLIDE 64

Building the Budget

64

Medicare Total Visits
Combine projected PDGM visits with PPS visits for bridge patients
Skilled Nursing
Physical Therapy
Occupational Therapy

Total SN Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM SN Visits 4,022 6,193 6,886 7,024 7,055 7,129 7,183 7,240 7,276 7,311 7,322 7,326 Total PPS SN Visits 1,183 257

Total SN Visits

5,205 6,450 6,886 7,024 7,055 7,129 7,183 7,240 7,276 7,311 7,322 7,326 Total PT Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM SN Visits 3,258 4,169 4,450 4,494 4,509 4,526 4,539 4,556 4,568 4,578 4,582 4,584 Total PPS SN Visits 710 154

Total SN Visits

3,968 4,323 4,450 4,494 4,509 4,526 4,539 4,556 4,568 4,578 4,582 4,584 Total OT Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM SN Visits 911 1,144 1,215 1,227 1,231 1,236 1,239 1,243 1,246 1,249 1,250 1,251 Total PPS SN Visits 473 103

Total SN Visits

1,385 1,247 1,215 1,227 1,231 1,236 1,239 1,243 1,246 1,249 1,250 1,251

SLIDE 65

Building the Budget

65

Medicare Total Visits
Speech Therapy
Medical Social Work
Home Health Aide

Total SN Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM SN Visits 123 159 171 173 173 173 173 174 174 175 175 175 Total PPS SN Visits 118 26

Total SN Visits

241 185 171 173 173 173 173 174 174 175 175 175 Total SN Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM SN Visits 71 89 95 96 96 96 97 97 97 97 97 98 Total PPS SN Visits 47 10

Total SN Visits

118 100 95 96 96 96 97 97 97 97 97 98 Total SN Visits Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total PDGM SN Visits 223 368 416 430 436 444 451 456 461 465 466 467 Total PPS SN Visits 237 51

Total SN Visits

460 420 416 430 436 444 451 456 461 465 466 467

SLIDE 66

66

Staffing Data & Assumptions

Total Days Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Total Total Days in Month 31 29 31 30 31 30 31 31 30 31 30 31 366 Non-Work Days 8 9 9 8 10 8 8 10 8 9 9 9 105 Workdays 23 20 22 22 21 22 23 21 22 22 21 22 261 FTE Hours per Month 184 160 176 176 168 176 184 168 176 176 168 176 2,088 Normal Work Week Paid Time Off (PTO) Days % Productivity Visits Available Staff FTEs Number of hours worked per year 2,080 Sick Days 10 4% SN Visits per Day 5.00 SN FTEs 70.00 Number of hours worked per week 40.00 Vacation Days 20 8% PT Visits per Day 5.00 PT FTEs 25.00 Number of hours worked per day 8.00 Admin 9 3% OT Visits per Day 5.00 OT FTEs 8.00 Number of days worked per week 5.00 Holidays 6 2% ST Visits per Day 5.00 ST FTEs 1.00 Overtime Rate 0.00% Total PTO Days 45 17% MSW Visits per Day 3.50 MSW FTEs 0.50 HHA Visits per Day 5.50 HHA FTEs 2.00

SLIDE 67

Building the Budget

67

Staffing
Skilled Nursing Monthly

Total Days Jan-20 Feb-20 Mar-20 Apr-20 Total Skilled Nursing Visits 5,205 6,450 6,886 7,024 Daily Productivity Expectations - Skilled Nursing 5.00 5.00 5.00 5.00 Productivity Expectations - Gross Skilled Nursing 115 100 110 110 Productivity Expectations - Net Skilled Nursing 95 83 91 91 Calculated FTEs Needed Skilled Nursing 54.74 78.00 75.71 77.22 Actual FTEs Skilled Nursing 75.00 75.00 75.00 75.00 Over/(Under) Staffed Skilled Nursing 20.26 (3.00) (0.71) (2.22) Full Time Staff Hours Skilled Nursing Full Time 13,800 12,000 13,200 13,200 Skilled Nursing Per Diem

479

124 391

SLIDE 68

Building the Budget

68

Staffing

Staffing Required FTEs Needed Current FTE Additional Staff Needed SN 77 75

2

PT 50 48

2

OT 14 14 ST 2 2 MSW 1 1 HHA 5 5

SLIDE 69

Financials

69

Financial Projection

Year Ending 2020 Total Medicare Revenue 29,873,838.57 $ Sequestration 597,476.77 $ Total Net Revenue 29,276,361.80 $ Salaries & Wages Nursing 6,970,761.46 $ Physical Therapy 4,484,444.61 $ Occupational Therapy 1,253,769.09 $ Speech Therapy 180,387.64 $ Medical Social Worker 45,000.00 $ Home Health Aides 227,637.87 $ Total 13,162,000.68 $ Benefits @ 18% 2,369,160.12 $ Total Salaries & Benefits 15,531,160.81 $ Mileage 890,000.00 $ Supplies 500,000.00 $ Total Direct Costs 16,921,160.81 $ Gross Margin 12,355,201.00 $ Gross Margin % 42%

SLIDE 70

Other Considerations

70

Admission Source
Do you expect your referral sources to change?
Medicare Advantage
Will Medicare Advantage plans go to PDGM or stay PPS?
New requirements?
Contract terms
New York Medicaid EPS going to PDGM?
Telehealth ROI (Therapy)
In House/ Outsource Coding/Quality Review

SLIDE 71

Other Considerations

71

Any changes based on new SNF payment model?
Therapy Utilization
Referrals by Clinical Grouping
Usage of LPN and Therapy assistants.
30 Day review process
G/L adjustments based on Admission Source
Cash Flow Projection
Factoring in RAP phase out and 30-day claim cycle.
AR Reserve
QE write offs

SLIDE 72

Cash Flow Impact

72

Timeline Variables
RAP Billing
2020 – RAP 20%, Final 80%
2021 – Phase out of RAPs
OASIS Completion/QA, receipt of verbal orders
PDGM RAP 2 in most cases will use the same OASIS as PDGM RAP 1 leading to quicker billing timeline
Final Claim Billing
Timely receipt of signed orders
Timely completion of F2F
Timely receipt of visit and supply information

SLIDE 73

Cash Flow Impact

73

Sample Billing Timeline

SLIDE 74

Cash Flow Example Scenario

74

Assumptions

1. PPS - 1 RAP/1 FC per day 2. Length of Stay = 60 days 3. $3,300/PPS Claim ($1,980 RAP/$1,320 FC) 4. PDGM – 1 admission per day 5. $1,900/PDGM 1 Claim ($380 RAP/$1,520FC) 6. $1,400/PDGM 2 Claim ($280 RAP/$1,120 FC) 7. Billing Timeline Assumptions Outlined on Prior Slide

SLIDE 75

Cash Flow Example Scenario

75

Dec Jan Feb Mar Apr PPS – RAP Reimbursement $61,380 $29,700 PPS – Final Claim Reimbursement $40,920 $40,920 $36,960 $29,040 PDGM – RAP 1 Reimbursement $6,460 $10,640 $11,780 $11,400 PDGM – Final Claim 1 Reimb $25,840 $42,560 $47,120 PDGM – RAP 2 Reimbursement $4,433 $7,233 $7,000 PDGM – Final Claim 2 Reimb $17,732 $28,932 Total $102,300 ,300 $77,0 ,080 80 $77,8 ,873 73 $108,345 ,345 $94,4 ,452 52 $ Difference from December ($25,200) ($24,427) $6,045 ($7,848) % Difference from December

25%
24%

6%

8%

Daily Cash $3,300 $2,486 $2,781 $3, 495 $3,148

SLIDE 76

Questions?

Rob Simione, CPA, Director robsimione@Simione.com New York, NY

76

SLIDE 77

800.949.0388 | Simione.com

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