Preparing for PDGM: A Must-Do Checklist to Evaluate Your Agencys - PowerPoint PPT Presentation

Preparing for PDGM: A Must-Do Checklist to Evaluate Your Agency’s Readiness

Overview  PDGM Framework  General Checklist  Revenue Cycle August 2018 2

PDGM Framework

PDGM Details Medicare History  IPS: 1998 - 2000  Reduced per-visit payment rates  Established beneficiary cost limit for home health agencies  PPS: 2000 – 2019  Introduced episodic billing (60-day episodes)  Refined in 2008  Reimbursement based on episode timing, clinical/functional OASIS scores, therapy volume, and supply volume  PDGM: Beginning 2020  Reduces billing period to 30 days  Aligns reimbursement with resource use 4

What is PDGM? Summary of Changes  Implementation date proposed to be for periods of care beginning on or after January 1, 2020  Budget neutral – huge win compared to the estimated $950M reduction in payment of HHGM  Replaces 60-day payment episodes with 30-day periods  OASIS still only required every 60 days  Return of sudden change in condition (SCIC) adjustments 5

What is PDGM? Summary of Changes (Cont’d)  Eliminates the use of the number of therapy visits in payment determination  Increase total number of case-mix weights from 153 to 432  Modification to visit thresholds for low utilization payment adjustments (LUPAs)  Model based on claims and cost report data  Estimated 959,410 (14.2%) claims excluded due to non- linked OASIS  7,458 cost reports 6

What is PDGM? Patient-Driven Groupings Model 7

General Checklist

Preparing for PDGM General Checklist  Educate staff in all departments  Determine agency’s estimated revenue impact  Understand which PDGM components will have the largest impact on your agency (positive and negative)  Prepare/budget for cash flow delays during PDGM transition  Contact your Senators and Representatives to support legislation to eliminate the behavioral adjustment (8.01%) 9

Operational Impact General Checklist  Create an internal PDGM steering committee  Develop reporting on key indicators driving reimbursement under PDGM  Evaluate current processes and workflows  Are these sustainable under PDGM?  Perform a coding/OASIS audit  Identify potential impact of QE, comorbidities, etc.  Establish strong interdepartmental communication 10

Preparing for PDGM Leveraging Technology  Contact your EMR and ask what they are doing to prepare  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 EMR updates made?  Documentation Management/Orders Tracking  Facilitate compilation, storage, and review of referral documents  Streamline start of care workflow  Allow for documentation to be analyzed based on specific categories (i.e. referral source)  Maximize use of e-fax or electronic communication 11

Preparing for PDGM Leveraging Industry Resources  HCA NY, NAHC, and other advocacy groups  Several seminars, webinars, and workshops available  There are expert organizations that can assist providers with preparation  Consulting groups have purchased Limited Data Set (LDS) from CMS 12

Revenue Cycle

Operational Impact Intake  Understand the impact of your primary referral source  Analyze current marketing and referral relations strategies  Includes education to referral sources  Obtain as much information as possible at time of referral  Strong communication with Scheduling Department  Develop Intake checklist Key Metrics to Monitor  Percentage of current referrals that are institutional vs. community  Most common clinical groupings referred by each referral source 14

Operational Impact Patient Management  Determine appropriate visit frequency at start of care  Therapy still plays an important role in the care plan  Streamline identification process for HIPPS  Allows for more effective LUPA management  Ensure timely completion of OASIS/visit documentation 15

Operational Impact Patient Management  Establish processes to continuously assess patient during care  ROC assessment/SCIC will change HIPPS under PDGM Key Metrics to Monitor  Turnaround time for OASIS completion/submission to CMS  Estimated LUPA percentage under PDGM  Average length of stay 16

Operational Impact Coding  Accurate and complete coding is essential  Will determine Clinical Grouping and Comorbidity Adjustment  Develop strong education back to clinicians on issues identified in coding/OASIS audit  Include all pertinent diagnoses – up to 25 on claim 17

Operational Impact Coding  Be cognizant of diagnoses that fall under the Questionable Encounter (QE) classification  Estimated 14% of periods would be classified as a QE in current claims data set  If significant change in condition occurs, recognize that coding may need to be updated Key Metrics to Monitor  What percentage of periods would fall under a QE status?  What percentage of periods would qualify for a comorbidity adjustment? 18

Operational Impact Orders Tracking  Shorter billing period makes quick turnaround on signed orders even more important  Incorporate face-to-face documentation into orders process  Plays a role in accurate coding and timeliness of billing  Evaluate how quickly agency is getting new orders to physicians  Minimize use of hard copy mail submissions  Minimize delays in checking signed orders into EMR  Educate physicians on new regulations and increased urgency on orders receipt 19

Operational Impact Orders Tracking  Establish streamlined process for following up on outstanding orders  Follow-up at the physician level  Reach out to physicians every seven (7) days until orders are returned signed  Utilize phone calls on top of resubmission of orders  Develop escalation process if orders not being signed (i.e. courier) Key Metrics to Monitor  Average days after start of episode that 485 is sent to physician  Volume of verbal orders generated after start of episode  Average turnaround time for receipt of signed physician orders 20

Operational Impact Supply Management  Ensure all supplies are still added to claims/cost reports  These will be factored into rate setting for clinical groupings  Remain cognizant of the differences in reimbursement between clinical groupings  CMS will allow for remote patient monitoring on cost reports  How does this factor into care delivery, case management, and supply utilization? Key Metrics to Monitor  Timeliness of supply entry into EMR  Delays in billing due to untimely entry of supplies  Volume of claims submitted without appropriate supplies included 21

Operational Impact Billing  Evaluate if staffing levels/productivity can support increase in claim volume  Streamline pre-bill audit process to account for shorter timeframe to resolve issues prior to final claim  Monitor claims to identify Medicare processing errors  Analyze impact of RAP changes  Payment decreased to 20% of expected amount in 2020 22

Operational Impact Billing  Develop strong communication of billing issues to other revenue cycle departments  Maintain strong non-Medicare collections processes to help support agency during cash flow interruption Key Metrics to Monitor  Days to RAP/final claim  Frequency of billing  Claim volume on outstanding accounts receivable  Volume of unbilled claims 23

Operational Impact Finance  Adapt accounting model to 30-day period format 24

Questions? Mike Freytag Brian Harris Managing Principal Consulting Director MikeFreytag@BlackTreeHealthcare.com BrianHarris@BlackTreeHealthcare.com (610) 536-6005 ext. 704 (610) 536-6005 ext. 732 Outsourcing Education Consulting