PDGM is Coming
Effective January 1, 2020, Medicare home health reimbursement will be made using the Patient-Drive Grouping Model (“PDGM”). Some of the changes made by PDGM to existing PPS reimbursement are as follows:
New payment episode timings: PDGM will break up the standard 60-day episode of care into one of two 30-day periods. That means 30-day periods will be implemented as a basis for payment vs. the 60-day periods used now. Each 30-day period is grouped into one of 12 clinical categories based on the patient’s main diagnosis.
Payment groupings: PDGM will increase the number of payment groupings and unique case-mix potential from 153 to 432. PPS allowed for 153 combinations, but with PDGM each 30-day period can be categorized into one of 432 case-mix groups.
Elimination of therapy thresholds: PDGM will eliminate therapy thresholds as a primary determinant of reimbursement, so therapy visits will no longer determine reimbursement. The number of therapy visits will no longer impact the case-mix weight.
OASIS assessments will remain on a 60-day cycle, but there will be two payment periods within that cycle instead of one. Based on an OASIS assessment, new 30-day periods will be categorized according to five subgroups.
Low Utilization Payment Adjustments (LUPAs): LUPAs will undergo a major change, as each Home Health Resource Group (HHRG) will have its own LUPA visit threshold (2-6 visits) and the LUPA count will reset every 30-day payment periods.
Cost Reporting Changes
Hospice Cost Reports – CMS has released Transmittal 3 which only increases the requirements of the Hospice Cost & Data Report which was issued at the end of 2014. Now, CMS has released the proposed rule regarding hospice payment rates to be effective October 1, 2019. The hospice payment rates have been substantially modified as a result of the proposed rebasing. This rebasing is primarily the result of cost report submissions. The accuracy of the Hospice Cost & Data Report has never been more important.
Home Health Agency Cost Reports – CMS has released a new “proposed” Home Health Agency Cost Report which is proposed to be effective for cost reporting years ended on or after December 31, 2019. The new cost report requires substantial changes in capturing costs and statistics. Cost report data will impact PDGM reimbursement in future years; accordingly, the new report must be taken seriously by all home health agencies. Comments have been submitted on the proposed cost report. Due to extensive comments issued, the release of the “final” report appears to have been delayed. We expect that implementation of the “new” cost report will be delayed beyond the December 31, 2019 cost reporting period.
Home Office Cost Reports – CMS has released a revised Home Office Cost Report (CMS 287-19), which is effective for cost reporting periods beginning on or after October 1, 2019. The revisions include the addition of new schedules, the removal of obsolete information, and general layout changes on all schedules.
Eblast News Alerts
The Health Group, LLC is pleased to provide the public with three separate eblast services:
Health Care Alert – brief coverage of financial and compliance issues impacting healthcare providers.
Home Health Alert – topics of timely importance to home health and home care providers.
Hospice Alert – coverage of financial and compliance issues specifically for hospice providers.
If you, or someone in your organization this this would be of benefit, we would be pleased to add you to this service. Contact us at firstname.lastname@example.org. We are currently in the process of providing access to historical Eblast releases which are available on our “News” page for your review.
Medicare Enrollment to Include Additional Disclosure
The U.S. Centers for Medicare & Medicaid Services (“CMS”) has issued the Final Rule regarding “Program Integrity Enhancements to the Provider Enrollment Process”. The Final Rule, effective November 4, 2019, will implement a provision of the Social Security Act (the Act) that requires Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) providers and suppliers to disclose any current or previous direct or indirect affiliation with a provider or supplier that – (1) has uncollected debt; (2) has been or is subject to a payment suspension under a federal health care program; (3) has been or is excluded by the Office of Inspector General (OIG) from Medicare, Medicaid, or CHIP; or (4) has had its Medicare, Medicaid, or CHIP billing privileges denied or revoked. This provision permits the Secretary to deny enrollment based on such an affiliation when the Secretary determines that the affiliation poses and undue risk of fraud, waste, or abuse. Disclosures will not be required until such time as CMS has updated the Medicare enrollment forms. The identification of affiliations and reporting disclosable events will occur, upon CMS request, at initial enrollment and revalidation of Medicare enrollment.
MedPAC Examines Hospice CAP
The Medicare Payment Advisory Commission (“MedPAC”) is considering a recommendation that Congress reduce the individual hospice beneficiary aggregate payment CAP. Also, under consideration is a potential recommendation to adjust the CAP according to the wage index for different geographic regions to reflect the varying costs of care in different parts of the country.
The Health Group, LLC has long believed that the use of a single CAP across the country discriminated against providers in certain locations; however, implementation of a geographical CAP must be carefully considered to avoid unintentional consequences of such action. Likewise, any across the board reduction to the CAP as a means of simply reducing hospice expenditures relating to long lengths of stay could have significant impact on access to care and create other unintended consequences.
CMS Updates ERS Request Process and Data
CMS has recently updated the “Medicare Financial Management Manual” regarding debt collection. The Manual discusses in significant detail the process used by the Medicare program in notifying providers of debt as well as the recovery process, including requests by providers for an Extended Repayment Schedule (“ERS”).
Providers generally have 15 days from the date of any demand for repayment to file required documentation supporting a request for ERS. Accordingly, it is important that providers anticipating a demand for repayment prepare for making such a request, if that is the provider’s plan.