Optimize Your Revenue Cycle for PDGM Success June 4, 2019 - PowerPoint PPT Presentation

Optimize Your Revenue Cycle for PDGM Success June 4, 2019

● Introductions & format ● PDGM summary ● Revenue cycle Impact ● Preparing for PDGM ● Workflow and technology processes Welcome ● Questions

Webinar Format Use the Questions section on the • GoToWebinar panel to submit questions Webinar will be recorded and a link • to the recording will be emailed to all registrants.

PDGM Summary

Annie Erstling Chief Strategy Officer Erin Masterson Consulting Manager

Patient Driven Groupings Model (PDGM) 6

LUPAs PPS: ● 60-day episode with four ○ or fewer total visits are paid per visit PDGM: ● LUPAs now have variable ○ thresholds based on HHRG Different level for each ○ of the 432 HHRGs 10th percentile value of ○ visits for each threshold LUPA Add-on remains ○ 7

Billing For billing purposes, PDGM proposes to keep the RAP/final claim billing methodology ● CMS estimates the median time to submit a RAP is 12 days so they are soliciting ○ comments on if this makes sense 5% of RAPs not submitted until after day 60 ○ New agencies as of 1/1/2019 would not receive RAP payments under PDGM but required ● to submit a “no pay” RAP Potential Notice of Admission in the future ○ 8

Billing Source of admission indicated by occurrence code on the final claim only (not included on ● RAPs) Medicare will automatically adjust claim if community is indicated but an institutional ○ source submits Medicare claim Clinical Groupings and Comorbidity Adjustment based on diagnoses on the CLAIM, not the ● OASIS Up to 25 diagnosis codes can go on claim compared to 6 on OASIS ○ 9

Miscellaneous OASIS still completed every 60 days ● PEPs (Partial Episode Payments) have same methodology ● Outliers have same methodology, although fixed dollar loss would need to change ● Based on current rules, 4.77% of estimated total payments would be outlier dollars ○ CMS requirement that number cannot exceed 2.5% ○ Non Routine Supply (NRS) Add-on payments eliminated ● 10

Revenue Cycle Impact

General Educate all staff ● Establish strong interdepartmental communication ● Develop reporting on key indicators driving reimbursement under PDGM ● Establish internal PDGM steering committee ● Key Metrics to Monitor: Productivity levels for all departments ● Staffing levels required to implement optimal workflows under PDGM ● 12

Marketing Understand the impact of your primary referral source ● Analyze current marketing and referral relations strategies ● Includes education to referral sources ○ Determine what a “good” referral is in the future ● Key Metrics to Monitor: Admission Percentage ● Most common clinical groupings referred by each referral source ● 13

Intake Obtain as much information as possible at time of referral ● This will be vital in supporting coders ○ Strong communication with Scheduling Department ● Minimize gaps in entry of referral information into EMR ● Develop Intake checklist ○ Key Metrics to Monitor: Productivity ● Early/Late Percentage ● Community/Institutional Percentage ● 14

Case Management Interdisciplinary communication ● Therapy still plays an important role in the care plan ○ LUPA management under new structure ● Early identification of HIPPS allows for more effective LUPA management ○ Continuing assessment of patient during care ● ROC assessment/SCIC will change HIPPS under PDGM ○ Supply management ● Key Metrics to Monitor: Turnaround time for OASIS completion/submission to CMS ● LUPA percentage ● Average length of stay ● Periods per patient ● Periods per patient ● 15

Coding Accurate and complete coding is essential ● Will determine Clinical Grouping and Comorbidity Adjustment ● Include all pertinent diagnoses ● Up to 25 diagnosis fields available on claim; all of these will be considered when determining ○ comorbidity adjustment Be aware of diagnoses that would be considered Questionable Encounters ● If significant change in condition occurs, coding may need to be updated ● Key Metrics to Monitor: Current - what percentage of periods would fall under a QE status? ● Average number of diagnoses per claim ● Comorbidity percentage – no, low, high ● Days to RAP ● 16

Orders Tracking Shorter billing period makes quick turnaround on signed orders even more important ● Timely receipt of F2F documentation also more important ● What is order submission process? ● Determine if current frequency/method of follow-up with physicians is efficient ● Education to physicians ● Key Metrics to Monitor: Average days after start of episode that 485 is sent to physician ● Volume of interim orders generated after start of episode ● Average turnaround time for receipt of signed physician orders ● 17

Billing Volume of claims increases ● Shorter timeframe to resolve all pre-billing issues prior to final claim ● Monitor claims to identify Medicare processing errors ● Future of RAPs is uncertain ● Communication with coders on QE ● Key Metrics to Monitor: Days to RAP/Final Claim ● Frequency of billing ● Claim volume on outstanding accounts receivable ● Volume of unbilled claims ● 18

Changes in Claim Management CMS will calculate reimbursement based on prior claims in common working file (CWF), ● diagnoses/visits on submitted claim and OASIS in QIES system, not HIPPS listed on claim Need to investigate all remaining balances on A/R prior to adjusting off in EMR ○ Pricer not implemented until 1/6/2020 ○ Occurrence Codes for institutional referral sources ● OC 61 – acute inpatient hospital stay ○ OC 62 – SNF, IRF, LTCH, IPF ○ Occurrence Code 50 indicates assessment date ● Treatment authorization code no longer required on claims ● 19

Preparing for PDGM

Checklist Educate entire staff ● Determine estimated revenue impact ● Agency-level detail available on CMS website under “Home Health Agency (HHA) Center” ○ provider section Download PDGM grouper ○ Limited Data Set (LDS) made available by CMS ○ Evaluate current agency data for key PDGM indicators ● Perform coding/OASIS audit ● Identify potential impact of QE, comorbidities, etc. ○ Evaluate current processes and workflows ● Are these sustainable under PDGM? ○ 21

Leverage Industry Resources National, state organizations, and other advocacy groups ● Attend workshops, seminars, and webinars ○ Subscribe to written publications and listservs ○ There are expert organizations that can assist providers with preparation ● Consulting groups have purchased Limited Data Set (LDS) from CMS ● 22

Workflow Processes & Technology

Process & Technology Success depends on people, process & technology alignment ● Review your internal processes, evaluate your teams and resources & seek out best in breed ● technology solutions Work directly with your EHR or ancillary technology companies to determine PDGM specific ● enhancements 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 updates made? ○ 24

Evaluate and optimize internal Evaluate referral sources ● ● processes with real-time Streamline intake process ● productivity and efficiency Ensure accurate and complete Data & Referrals ● insights intake information Analytics & Intake Data model for agency specific Turn intake documents into ● ● PDGM assessment actionable data Predictive revenue trending ● PATIENT Finance & Rev Cycle Improved communication and ● collaboration between cross-functional teams Clinical Accurate & consistent wound ● Care measurements Support timely and expedited ● Seamless integration with EHR ● billing with clear documentation and processes Timely receipt of signed and ● Quality dated orders, plan of care and Support timely and expedited ● F2F billing with clear documentation Obtain electronic signatures ● & processes Timely receipt of signed & dated ● orders, plan of care & F2F 25

Questions? Erin Masterson Consulting Manager ErinMasterson@BlackTreeHealthcare.com (610) 536-6005 ext. 712 Annie Erstling Chief Strategy Officer aerstling@forcura.com (904) 707-2902