Welcome to the HealthPRO Heritage Blog

The industry agrees:  With the roll out of such a complex new system like PDPM…there are several risks and so much at stake.  As such, here’s a question worth asking:

Does your facility have a proactive PDPM compliance, or verification process in place? If yes…good by you! But even a solid, well-functioning version of today’s process MUST be retooled in preparation for PDPM & Beyond!

The Home Health industry continues to evolve: the updated Conditions of Participation (CoPs) in 2018, then OASIS-D and the Review Choice Demonstration (RCD) in 2019, and now the Patient-Driven Groupings Model scheduled for 2020, just to name a few!  Change can be exhausting, so it is comforting to know that some things aren’t changing...like documentation!

Tuesday was the day! On July 30, CMS released the FY 2020 Final Rule for Medicare payment rates and quality programs. This is the moment we have all been waiting for. PDPM is 9 short weeks away, and the industry finally has clarifications RE: the new payment model.

Following the recent NAHC Financial Management Conference in Chicago, HealthPRO Heritage representatives in attendance outlined principal key concerns affecting home health agencies going forward into PDGM implementation. 

On July 11, 2019, Centers for Medicare & Medicaid Services (CMS) issued the 2020 Home Health Prospective Payment System (PPS) Proposed Rule (effective January 1, 2020). While many of the provisions in the original Patient-Driven Groupings Model (PDGM) remain unchanged, the home health experts from HealthPRO Heritage at Home offer the following summary of important updates:

Among the many important decisions related to the PDPM transition is the question of whether SNFs and their rehab partners should accept students for clinical affiliations.  As strategy consultants and leaders in therapy, HealthPRO Heritage offers this guidance: 

As PDGM edges closer, there is rising concern and tension around the submission of claims that contain primary diagnoses that do not fall into one of the 12 clinical groupings established by CMS. Such primary diagnoses are known as "Questionable Encounters" (QEs). QE codes are "too vague," meaning the code did not provide adequate information to support the need for home health services. CMS listed 43,287 eligible primary diagnoses codes in their PDGM Grouper Tool. 

Under PDGM, claims for QEs will be sent back to the agency as "Return to Provider" (RTP) since CMS will not be able to assign the 30-day period to one of the 12 PDGM clinical groups. 

Examples of the Top 25 QE Codes:

Start preparing TODAY to guarantee your agency's success in the future. With ~6 months to go, ask yourself: Are you on track for the transition to PDGM? Do you have the right therapy partner?

HealthPRO Heritage at Home has compiled the following PDGM Preparation Checklist that can help organize a plan of action for home health agencies affected by the future of PDGM:

Decisions. Decisions. Since the industry began wrapping their heads around RCS-1 two+ years ago, SNFs continue to weigh the pros and cons of retaining in-house therapy vs. an outsourced model. Questions arise: What does payment reform mean for SNFs with their own program? Is there a financial or operational advantage to transitioning from full service to in-house or a “managed” in-house model?

It can be easy to get lost in the details of PDGM and forget how vital outcomes and ratings are in driving overall agency success.  It’s one of the biggest reasons why appropriately managing therapy in PDGM is a key competency.

In HealthPRO Heritage at Home's recent survey with the National Association for Home Care and Hospice regarding therapy in PDGM, 48% of respondents anticipate less therapy utilization. Agencies should be cautioned on cutting therapy utilization given the focus on functional assessment and outcomes.  Functional assessments - completed best by a skilled therapist - will contribute significantly to payment in PDGM, while also continuing to drive publicly reported outcome measures and star ratings.