by Darcey Trescone, RN, BSN
Recently, we caught up with Chris Attaya, VP of Product Strategy at Strategic Healthcare Programs (SHP), to discuss utilization under PDGM and why this topic is key to an agency’s success. For clarity, we present Attaya’s insights below with our questions removed.
The revenue changes from how agencies had been paid to what they’re going to be paid can be significant. What is interesting when looking at profitability based on nationalized standard rates and costs under PDGM is CMS has recalibrated revenues based on the costs. The case weight, visit volume, and supply cost data of today under PDGM demonstrates that the profitability percentage by clinical grouping will be about the same. That is how CMS designed PDGM. Overall, we can expect to see revenue decrease depending on how agencies adjust to expected behavioral changes, but there is still opportunity to make a profit.
The level of success for an agency will depend on knowing the mix of clinical groupings they service, and the detailed care they are providing to reach good outcomes. It should not be a surprise that the key element in planning and preparing for January one under PDGM is utilization. Internal process changes to accommodate shorter billing periods will not be enough.
Utilization includes not just the number of visits but also the care plan we provide by clinical grouping while addressing the socioeconomic and other risk factors for the populations served.
Utilization is going to take fine tuning. Visit utilization that is benchmarked by HHRG by period and by period sequence (first, second, third, etc.) is important. Comparing this data with quality outcomes to understand what the best practice should be for populations will be ideal. Identifying the right number of visits, the right resources and the right care plan to get good quality outcomes and then trying to manage to this will be important under PDGM.
CMS has been doing risk adjustments on outcomes for some time now. Their calculations include an agency and national predicted score based on these risk factors and they have recently updated their models with Oasis D data. So, we already kind of have the data needed to predict how a patient should do based on all potential risks.
SHP captures 65-70% of all Oasis episodes within our data set when comparing to the fee for service (FFS) episodes that Medicare processes yearly. We are releasing in October a PDGM Preview report that allows agencies to look at their 2019 payment episodes as
What we are looking to provide as agencies start the year is PDGM patient level detail reports on both a stay and period level. This will allow agencies early on to identify the PDGM grouping for those patients who were admitted January one. Shortly after this we will be providing Scorecard level data that allows an agency to benchmark against others in their organization by team, by clinician, etc. as well as by SHP state and national benchmarks.
About Strategic Healthcare Programs
Strategic Healthcare Programs (SHP) is a leader in data analytics and benchmarking that drive daily clinical and operational decisions. Our solutions bring real-time data to post-acute providers, hospitals, and ACOs to better coordinate quality care and improve patient outcomes. Since 1996, SHP has helped more than 7,000 organizations nationwide raise the bar for healthcare performance. For more information visit www.shpdata.com.
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About the ayutor: Darcey Trescone, RN, BSN is a Healthcare IS and Business Development Consultant in the Post-Acute Healthcare Market with a strong background working with both providers and vendors specific to Home Care and Hospice. She has worked as a home health nurse and held senior operational, product management and business development positions with various post-acute software firms. To learn more visit www.TresconeConsulting.com. She can also be reached at darcey@tresconeconsulting.com.
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan (part 1) and Darcey Trescone (part 2)
by Tim Rowan, Editor and publisher of Home Care Technology Report
Part 1: Twenty-four months ago, before anyone had uttered “PDGM,” Tim experienced home health as a patient who had undergone total knee replacement. Medicare paid for nearly all of [the services he needed..
The more I study PDGM, the more I understand just how different next year’s typical home health patient’s experience will be from mine. …
Select Data CEO Ed Buckley has been analyzing data gathered from clients of his outsource coding service as well as industry-wide historical claims files. . [Key take-aways from my talk with Buckley are these:
Vigilance begins with intake, not with the assessment visit.
Documentation is still key.]….
“Based on our auditing experience, approximately 38 percent of records include errors with the primary diagnosis,” Buckley continued. “If not corrected, that will definitely affect agency reimbursement next year. And, with the addition of non-payment codes or “questionable encounters” under PDGM, these errors can prove even more costly. In addition to the primary code, the co-morbidity adjustment with PDGM also has the potential to affect reimburseement, and greatly depends on complete documentation from the physician as well as reconciliation with agency documentation.”
New No No’s
There is language that referring physicians use fairly frequently today – CMS says about 15% of the time – that may not be used under PDGM. They are descriptions of symptoms rather than a diagnosis. Starting in January, there will no longer be payment for symptom codes.
To adapt[and Tt maximize success with PDGM, Buckley then says HHAs need to take specific steps. Vigilance begins with intake, not with the assessment visit. The intake person who receives referrals from physicians absolutely must be on the lookout for any physician verbiage that describes a symptom rather than a disease or chronic condition. “Generalized muscle weakness,” for example, carries a symptom code, not a diagnosis code, and it will no longer generate a payment. To prevent symptom language before a referral even reaches the intake department, Select Data recommends to its clients that they develop a carefully planned physician education program.
Meet with your high-referring physicians and tell them, “You can’t do this anymore; I won’t get paid.”
Educate referrers on what codes are no longer eligible for payment with PDGM and why.
Produce educational documents that explain the new rules, using examples of what is no longer acceptable and what specifically will now be required.
Teach your intake personnel that such unacceptable referrals must be returned to the physician for more information about the diagnosis and the patient’s condition and less about the patient’s symptoms.
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
Part 2: PDGM Demands on Efficiency
Former CMS OASIS coordinator and Founding President of OperaCare, LLC Michael McGowan discussed with us how HHAs can thrive with PDGM
Michael McGowan is no CMS critic. As a former OASIS coordinator for Region IX, he views PDGM as a logical move to correct some ineffective or inefficient habits that have crept into home health agency practices over the years.[Obstacles about reaching many of PDGM goals are noted by the author,in this HCTR article]
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
Coding and OASIS Experts Deliver Severe PDGM Forecasts (10/9/2019)
In this episode of our ongoing PDGM series, we spoke with three experts this week. They have intimate knowledge of claims data, OASIS and other clinical documentation errors, and coding rule changes.
Court Sides With Medicare Providers Against CMS Auditors (10/9/2019)
CMS auditors can no longer file a False Claims Act indictment just because their doctor disagrees with yours.
Axxess to Share Positive P
DALLAS, Tex. – October 8, 2019 – Axxess has a positive view of the impact of the forthcoming Patient-Driven Groupings Model [PDGM] for its clients. At the National Association for Home Care and Hospice (NAHC) 2019 Home Care and Hospice Conference and Expo, Axxess will share the resources it has been providing its clients and the industry to prepare for this important change.
“Axxess has been providing PDGM resources for several months to prepare our clients and the industry for the changes to the payment model,” said founder and CEO John Olajide. “PDGM-specific enhancements in our solutions, our on-demand educational resources, and nationwide training workshops are helping to thoroughly prepare our clients and the industry. In Seattle, we will share some of these enhancements.”
[A selection of several planned presentations at NAHC 2019 are:
“Creating New Revenue Streams Through Specialty Programs”
Presenter: Tammy Ross RN, BSN, MHA; and “Collecting Accurate and Professional and OASIS Items Without Losing Your Mind”
Presenter: Jennifer Osburn RN, HCS-D ICD-10-CM, COS-C
by Roger McManus, MBA
Eight Facebook “Nevers”
Facebook is committed to user experience. As such they focus strongly on how to balance your news feed with content you want and the ads they want you to see (it is how they make money).
If there is one thing consistent about Facebook it is change. They are constantly tweaking their algorithm to create a more effective user experience. To help you keep up with a few of the things that have become important to Facebook, I will lay out some things you should not do if you want your own Facebook news feed to get the best play.
***Never ask readers to do something for you directly. Do not ask them to like, share, or comment on a post. Let that happen naturally. Doing so will trigger a spam filter within Facebook.
**Never ask readers to buy anything. Pages are about sharing your interesting content, not pushing products or services. When Facebook sees “Download now” or “Click here for more information” or any other type of promotional language, you risk your organic reach. If you purchase a paid campaign, Facebook is perfectly happy with promotional language (it is how they make money.)
**Never link to YouTube videos in a Facebook post. Facebook has developed systems for you to upload native videos directly to your social media posts. Using them will increase your reach and engagement.
**Never use text-only posts. When you are creating Facebook content, include more than text. Posts that are all words do not show up as well in newsfeeds because they just are not that interesting. Always integrate photos, videos or other interesting visuals with your message.
**Never just repost content from others. Facebook loves original content. If you see something you want to pass along, download it and add it to an original post from you and TAG the original creator (so you are not plagiarizing). You will get more engagement and likes than the traditional sharing approach.
**Never just repeat yourself. Posting content that is similar to things you have posted before will lower your rankings. Switch things up with fresh, unique content. It will help you keep followers once you earn them.
**Never post without tagging. When a post tags a different Facebook page, it obtains better results. This is particularly true if your page tags a page with a similar audience. To not do so simply wastes an opportunity to get broader reach for your efforts.
**Never leave your Facebook Business Page incomplete. Fill out as many fields as possible. This gives potential followers a clearer idea of who you are and what your agency does.
Social media is all about building relationships, trustworthiness and authority. This is accomplished by posting interesting content related to your business, including visually stimulating imagery and not overtly promoting. You will be more widely read – and likely get more phone calls – than if you did not do so.
Does it seem a bit too much trouble? It can be challenging with the myriad of other things on your desk. If you decide to outsource the task, I should let you know that one of the services provided by Rowan Reputation Resources is auto-posting relevant content and images for you three times per week, leaving you the opportunity to post for yourself when you want (but, don’t have to).
Send us a note and we will get in touch to talk about it.
Roger McManus, MBA, is an online marketing consultant and a principal with our sister company, Rowan Reputation Resources. He can be reached at 719-992-0390 or Roger@RowanResources.com
RowanReputationResources.comRowanReputationResources.com
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
While the Telehealth Innovation and Improvement Act of 2019 languishes in the Senate Finance Committee, President Trump this week [October 12, 2019]signed an executive order telling Medicare to adopt more telehealth programs and pave the way for new technologies, including mHealth tools and services.
While visiting “The Villages,” a retirement community in Florida last week, Trump signed the order that calls on the Secretary of Health and Human Services to, within a year, “propose a regulation to provide beneficiaries with improved access to providers and plans by adjusting network adequacy requirements for Medicare Advantage plans to account for … the enhanced access to health outcomes made possible through telehealth services or other innovative technologies.”
Couched within political language that criticized “Medicare for All” plans promoted by some of his 2020 Democratic rivals, the order calls on CMS to “encourage innovation for patients” by “streamlining the approval, coverage, and coding process so that innovative products are brought to market faster, and so that such products, including breakthrough medical devices and advances in telehealth services and similar technologies, are appropriately reimbursed and widely available, consistent with the principles of patient safety, market-based policies, and value for patients.”
Specifically, the order calls on HHS Secretary Alex Azar to propose regulations and other actions which will provide more plan choices to patients by:
encouraging new Medicare Advantage (MA) benefit structures that make it easier to get a Medicare Medical Savings Account;;
Identifying and addressing challenges associated with parallel FDA and CMS reviews; and
Improving the Value-Based Insurance Design payment model so that it can embrace new technologies that save money and improve quality of care, among other needed ateps to getting the telehealth technologies well used by the Medicare population..
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
by Jeremy Powell, CEO, Acclivity Health Solutions
The Centers for Medicare & Medicaid Services’ Primary Care First (PCF) model is rolling out in 2020, and applications will become available in a matter of weeks. The Seriously Ill Population (SIP) model under PCF is designed to improve care for high-need, high-risk patients who currently receive fragmented or inadequate care. To do this, CMS will assign SIP patients to participating hospice programs, paying the providers to coordinate their care and avoid unnecessary hospitalizations.
There are numerous benefits to hospices participating in the SIP program, but first, your application must be accepted. Hospices interested in participating should take time to adequately prepare for their application based on what is known about the PCF program’s criteria and past CMS applications.
1. Begin drafting responses to narrative applications now.
2. Prepare to analyze patient data provided by CMS.
3. Determine staffing needs based on the new influx of SIP patients.
4. Review your technology against PCF’s criteria, including EHR, analytics, and reporting requirements.
5. Reach out to potential community partners to fill care delivery gaps (if any).
6. Prepare for discussions with Medicare Advantage payers who opt into the program.
[See the original HCTR article for more detail on preparing for each of the 6 steps.]
Jeremy Powell is the CEO of Acclivity Health. acclivityhealth.com/primarycarefirst.
©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan, Editor & Publisher of Home Care Technology Report0
Tim Rowan Home Care Technology Report
1) Sandata Technologies, LLC, a leading provider of Electronic Visit Verification and home health technology solutions, recently announced it has secured a significant growth equity investment from Accel-KKR, a leading Silicon Valley-based investment firm. [As indicated by Sabdata’s CEO Tom Dnderwood, this move is significant. He notes: The home care market in the US is growing rapidly and is on a path to become a strategic component of the overall health delivery network. Sandata is focused on providing innovative solutions to our customers who serve this market including State Payers, MCOs and Providers,” said CEO Tom Underwood. “We could not be more excited to partner with Accel-KKR
[Company information about Sandata Technologies and about Accel-KKR is provided in this article.]
2) Casamba launches HomeTherapy which allows contract therapy providers, clinicians and home health agency service providers to stay connected, and use the input module to keep contract PTs in the loop.
Fully-integrated into the Casamba Skilled EMR, HomeTherapy allows contract therapy providers, clinicians and home health agencies to stay connected, input e-referrals and share all rehab-related patient information on a single portal. Data in HomeTherapy is shared seamlessly across all Casamba Skilled applications ensuring accuracy of payroll, billing, reporting and other back office functions.
Company information about Casamba and its offerings is provided at the end of this article.
casamba.net
By Elizabeth Hogue, esq.
New Conditions of Participation (CoPs) went into effect for home health agencies on January 13, 2018. Hospices have recently come under withering fire from the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) regarding egregious survey deficiencies that may result in a crackdown by surveyors on hospices. Private duty agencies are subject to increasingly complex regulatory requirements for licensure and participation in Medicaid Programs in many states. Providers anticipate that they may receive unwarranted deficiencies as a result of these developments. Consequently, it is important for providers to know how to contest inappropriate deficiencies.
The first action providers should take when they disagree with deficiencies is to contest them in Plans of Correction (PoCs) submitted in response to Statements of Deficiency. Surveyors in some states have reacted negatively to this practice, especially in those states that have what may be described as “bad survey culture.” Some surveyors have even demanded that any language expressing disagreement in PoCs must be removed before PoCs will be accepted.
It is important for providers to know that the Centers for Medicare & Medicaid Services (CMS) has instructed providers to indicate disagreement in PoCs when they wish to contest deficiencies. Specifically, Chapter 3 of the State Operations Manual 3016E – Disagreement over Deficiencies states as follows:
A provider that disagrees with an SA finding regarding a cited deficiency or an acceptable PoC should be advised to annotate its position on the PoC, and should specify why the SA’s citation is not correct. In other words, providers that want to be heard regarding contested survey findings should express their disagreement in PoCs. Providers should express disagreement and the reasons for their disagreement in PoCs. They may also wish to request specific actions in PoCs, such as withdrawal of deficiencies. Providers must, however, be meticulous about how they contest deficiencies in PoCs.
Despite the fact that providers have expressed disagreement with deficiencies and perhaps have asked that the deficiencies be withdrawn,
In other words, providers that want to be heard regarding contested survey findings should express their disagreement in PoCs. Providers should express disagreement and the reasons for their disagreement in PoCs, such as They may also wish to request specific actions in PoCs, such as withdrawal of deficiencies. Providers must, however, be meticulous about how they contest deficiencies in PoCs. If providers do not also submit PoCs for each contested deficiency and challenges to deficiencies are rejected, providers may suffer adverse action, including loss of participation in the Medicare and/or Medicaid Programs, because they did not submit PoCs for every deficiency received.
In addition to challenging inappropriate deficiencies, providers should also utilize independence dispute resolution (IDR) processes that may be available to them. The processes for IDR may vary from state to state, so providers should identify state requirements and follow them. they did not submit PoCs for every deficiency received.
In addition to challenging inappropriate deficiencies, providers should also utilize independence dispute resolution (IDR) processes that may be available to them. The processes for IDR may vary from state to state, so providers should identify state requirements and follow them.
Using these two ways to contest inaccurate or inappropriate survey deficiencies has produced excellent results for many providers. Providers must be prepared to stand up for themselves during the survey process by contesting deficiencies using the mechanisms available to them.
©2019 Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author. This article appeared in Home Care Technology: The Rowan Report by permission.
