Revenue Cycle Management: Ensuring Accurate and Timely Reimbursement Under PDGM

For Medicare-certified Home Health Agencies (HHAs), the new Patient-Driven Groupings Model is certainly revolutionary. PDGM has been proclaimed by consultants and industry analysts as the most consequential regulatory and reimbursement transformation in the home health industry in two decades. Scheduled to become effective on January 1, 2020, the new payment methodology will affect how agencies treat referrals and develop plans of care. Agencies will need to actively manage each patient throughout the entire revenue cycle, from intake through discharge, in order to ensure accurate and timely reimbursement under PDGM. Here’s what you need to know now. 

30-Day Periods of Care and RAP Submission

Perhaps the most significant component of PDGM for HHAs is the change in payment units from 60-day episodes of care to 30-day periods of care. This change was mandated by the Bipartisan Budget Act of 2018. Starting on January 1st, HHAs will need to plan, deliver, document, and bill for care twice as often.

Currently, the 60-day certification period requires one Request for Anticipated Payment (RAP) and one final bill. Under PDGM, however, a RAP and a final bill must be submitted for each 30-day billing period (the second RAP can be submitted on or after day 31 of the certification period). This means that under PDGM every certification period will require two RAPs and two final claims, effectively doubling the amount of work for billers–and for other agency staff, as well.

RAP and Split-Percentage Payments

CMS (the Centers for Medicare and Medicaid Services) initially proposed a PDGM split-percentage payment of 60 percent for the first 30-day period of care, decreasing to 50 percent for all subsequent 30-day periods. This is no longer the case. 

CMS is now proposing to reduce the split-percentage payment to 20 percent for existing HHAs beginning in Calendar Year (CY) 2020, for both the initial and all subsequent periods of care. In order for split percentage payments to be made in CY 2020, HHAs will have to submit a RAP at the beginning of each 30-day period of care and a final claim at the end. 

In addition, CMS proposes the elimination of split-percentage payments for all HHAs beginning in CY 2021. A one-time notice of admission (NOA) would be filed by all HHAs beginning in CY 2021 to alert the claims processing system that a beneficiary is under a home health episode of care. 

Please Note: The phrase “existing HHAs” above refers to those agencies that were certified for Medicare prior to January 1, 2019. Newly enrolled HHAs (ie., agencies certified for Medicare participation on or after 1/1/19) will not receive split percentage payments beginning in CY 2020. 

Therapy Volume and Case Mix

The removal of therapy thresholds for case mix adjustment is another change that was required by the Bipartisan Budget Act of 2018. The current system relies on the number of therapy visits a patient receives to determine payment, but PDGM will eliminate therapy volume as a determinant of payment. PDGM ties therapy payments to patient clinical characteristics and patient needs, particularly through Functional Impairment Level. 

CMS will generate a PDGM case-mix weight for each of the 432 Home Health Resource Groups (HHRGs). Case mix weights are used to adjust the base payment amount. Higher resource need periods have a higher case-mix weight and receive a higher payment adjustment.

New LUPA Thresholds

A LUPA (Low-Utilization Payment Adjustment) is a standard per-visit payment for episodes of care with a low number of visits. Currently, LUPA occurs when there are four or fewer visits during a 60-day episode of care for any patient. Under PDGM, the LUPA threshold will vary by HHRG, and will be based on the 30-day period of care. New LUPA thresholds will range from two to six visits per 30-day period. 

Please Note: HHAs are used to a four-visit LUPA threshold over 60 days for every patient. Under PDGM, that will be the minimum threshold; agencies will be facing thresholds of up to 12 visits over 60 days for some HHRGs. 

The Bottom Line for HHAs

While HHAs currently are paid for the 60-day certification period regardless of discharge date, CMS experts suggest that 25 percent of claims under PDGM will receive only the first 30-day payment due to discharges within that time frame. An estimated 10-16 percent of claims will result in LUPA payments, and some estimates put LUPA reimbursement at a mere 15 percent of standard episode reimbursement. 

CMS experts forecast that another 12-15 percent of claims will receive no reimbursement at all under PDGM due to “questionable encounters” (ie., non-paying primary diagnosis or no supportive data), most of which can be attributed to coding errors. That leaves only 45-55 percent of patients that will receive payment for both 30-day periods under PDGM.

So what’s an agency to do?

Survival Requires Speed in Processes

At this point you’re probably thinking, “I get it: time equals money.” You may also be thinking “Help!”…You are not alone. HHAs across the country are scrambling to make the necessary modifications that will be crucial to agency survival under PDGM. 

Agencies need to assess all processes, from intake through final billing, and this assessment should be happening now. Cash flow under PDGM will require speed in these processes, and you can’t wait until January to ramp things up. Agencies need to be working now to gain that speed, so they are ready for the 30-day billing cycles—and all that they entail—beginning on January 1st. For NDoc® users, the NDoc Analytics Reports can help you track agency workflow and identify bottleneck areas.

In an interview with Home Health Care News, Anthony D’Alonzo, director of clinical strategy and innovation at Bayada Home Health Care, noted that care coordination and management will become increasingly important with PDGM, and HHAs will need to establish more interdisciplinary processes. “The hard part is figuring out quickly and at scale how you can have a team-based, coordinated approach to every person coming on service,” he said, “and aligning it with the PDGM classification system.”

Staff education should begin immediately, if it’s not already underway, to explain the necessary changes in documentation time and the need to closely manage all agency patients. Visit planning and team management must begin at SOC, so RNs and other clinicians should be educated about PDGM as soon as possible.

The First Five Days

For HHAs, the urgency for RAP submission is tied to reimbursement revenue. In addition, according to CMS, HHAs should submit the RAP as soon as possible after care begins to assure being established as the primary HHA for the beneficiary. 

The national average time for RAP submission is currently 12 days, but the recommended goal for PDGM is five days. The first five days from Start of Care (SOC) will be the most important for your agency: under PDGM, you’ll need to be accomplishing tasks in these five days that can take weeks to accomplish now. Indeed, the first 24-48 hours from SOC will be critical to optimize reimbursement. A HHA clinician must assess the patient’s needs and document a plan of care as soon as possible.

However, if you start the RAP on “Day 1,” you’re already behind!

The RAP Process Begins at Intake

The sooner the information is obtained, the faster it can be accessed for coding and billing, and you can’t wait until SOC to  begin the RAP process. Information and data gathering must start at Intake. 

Intake staff will need to ask a lot more questions and get a lot more information than they currently do, and they will need to work with schedulers to get all relevant disciplines (skilled nursing, PT, OT, etc) out to see the patient as soon as possible. 

Intake staff should be confirming and documenting data such as:

  • dates of inpatient admissions
  • admission and discharge summaries
  • homebound status
  • primary & secondary diagnoses
  • current medications list
  • documentation of face-to-face (F2F) encounter by allowed physician (or non-physician practitioner)

Please Note: Be sure to check your EMR settings to ensure that all of the data from Intake will flow to the referral for clinicians to use at SOC.

Day 1: SOC Visit

At the “Day 1” SOC visit, the clinician must complete the admission assessment, including all OASIS data. As LUPA thresholds are determined by HHRG classification, it will be critical for clinicians to thoroughly document the patient’s assessment and carefully consider each diagnosis. Patient diagnoses determine the PDGM comorbidity adjustment, which can significantly impact payments. PDGM will allow HHAs to designate one principal diagnosis and up to 24 secondary diagnoses, but clinicians need to remember that every diagnosis must be addressed in the care plan.

By the evening of Day 1, all SOC data should be ready for QA review. The clinician should have completed the following tasks:

  • Document the SOC assessment
  • Review OASIS assessment and indicate it as ready for review in the EMR
  • Complete the POC, making sure that every diagnosis is addressed and all physician orders are included
  • Plan visits for the entire certification period and document them on the patient calendar
  • Document patient’s outside appointments on the patient calendar (these should be accommodated in the visit planning schedule in order to reduce the number of scheduling conflicts and missed visits)
  • Document any assessment or POC concerns
  • Message any assessment/POC concerns directly to a quality assurance (QA) staff member or supervisor

Day 2: SOC Audit

In most HHAs, the SOC audit will be completed by QA staff. The QA auditor should be able to review the entire SOC visit, the POC, and the visit schedule.

Any corrections should be sent to the clinician, and the clinician should be messaged to complete the necessary corrections by the morning of Day 3. 

Once the audit is complete, the QA auditor should indicate in the EMR that OASIS is ready for coding. Most agencies use a certified coder, but if your QA reviewer is also your coder, then diagnosis coding should be part of the SOC audit process. (Some agencies allow coding by SOC clinicians during the assessment process; this should be carefully reviewed for optimal reimbursement under PDGM.) 

Please Note: Industry standards state that an auditor should be able to complete 13 audits in an 8-hour day, so you should make sure QA staffing is at the right level for your agency’s average patient admissions/day. NDoc users will find their Analytics Dashboard an invaluable tool in the audit process.

Day 3: Coding and Clinical Visit Documentation

Coding is Crucial

The certified coder should complete coding for all SOC documents and indicate they are ready for final review. Your EMR should allow easy identification of all SOC documents that are ready for coding (NDoc users just need to access the Analytics Dashboard). 

PDGM will designate a comorbidity adjustment of low, high, or none for each 30-day period based on the patient’s primary and secondary diagnoses (up to 24) reported on the claim. According to CMS, the comorbidity adjustment can increase payment by up to 20%. Selecting the appropriate diagnoses, in the appropriate order, is essential to accurate and optimal reimbursement. NDoc users can utilize the PDGM Evaluator to review and evaluate selected diagnoses.

Clinical Visits

The SOC clinician should make any necessary corrections to the SOC documentation or POC (as identified and communicated by the SOC Auditor on Day 2). 

By Day 3, additional disciplines should be making their initial visits and completing their documentation; all planned visits should be documented on the patient calendar.

Day 4: Final Review

In most agencies, it is the QA auditor who completes the final review prior to RAP submission. NDoc users can run the Analytics report for quick and easy access and review.

Day 4 tasks include: 

  • Review all diagnosis coding: does it make sense? 
  • Review corrections to the SOC documentation and visit schedule
  • Review the OASIS assessment and indicate as complete/ready for export in your EMR system
  • Review the POC: does it include orders from all involved disciplines? The goal is to have as few Physician Verbal Orders as possible; put everything possible on the POC.
  • Finalize the POC and send to physician

Please Note: Anyone can do the final review. The important thing is not who does it, but that it must be done.

Day 5: RAP Billing

HHAs can submit a RAP to Medicare as soon as all “ready to bill” requirements have been met:

  1. The OASIS (Outcome and Assessment Information Set) assessment is complete. CMS defines completion as “locked or export ready,” or finalized for transmission according to agency policy.  
  2. Physician verbal orders for home care have been received and documented (a signature on the  F2F is not required until final billing).
  3. A plan of care (POC) has been completed and sent to the physician.
  4. The first billable visit has been made and documented. (CMA may allow exceptions to this billable visit requirement for LUPA patients, but these exceptions have not been finalized and are not currently known).
  5. The physician must be enrolled in Medicare’s internet-based Provider Enrollment, Chain and Ownership System (PECOS).

Please Note: A signature on the F2F is NOT required for RAP. Agencies will want to review their EMR settings to ensure that there is no requirement for an F2F to be signed before a RAP is sent.

Day 6 and Beyond

Your commitment to new workflows can not be relaxed after the first RAP has been submitted. Agency survival under PDGM will depend on continuous adherence to and enforcement of these new, stricter time requirements. You will need an interdisciplinary team approach to effectively manage patients and optimize reimbursement under PDGM.

The Supervisor’s Role, Post-SOC

Whether it be a supervisor, QA, or other staff member at your agency, someone must be in charge of overseeing patient progress under PDGM.

Supervisors and care teams will need to discuss visit planning on an ongoing basis, remembering that therapy thresholds have been eliminated for case mix adjustment. It will be important to keep LUPA thresholds in mind as a patient’s diagnoses change or are resolved. The key is to plan visits to avoid LUPA in both the 1st and 2nd billing periods, whenever possible.

The supervisor and care team should review and discuss:

  • Will the patient have skilled needs for the next 30-day period of care (ie., will there be enough visits to avoid a LUPA)?
  • Have there been any major changes with the patient (ie., any new or changed diagnoses)?
  • Are outstanding orders necessary and appropriate?
  • Is there anything outstanding for billing:
    • Has OASIS been exported?
    • Has the POC been signed?
    • Have all scheduled visits been made, documented, and exported to billing?
    • Has the F2F been signed?
    • Have all physician verbal orders been signed?

The Clinician’s Role, Post-SOC

Ongoing visit documentation will need to address each of the diagnoses that were included in the comorbidity adjustment. NDoc users will benefit from new protocols that can be triggered to help clinicians focus on charting for secondary diagnoses. 

Clinicians must:

  • Document any changes to 2nd period diagnoses. NDoc users can utilize a new type of order that will be formatted to show coding changes for new diagnoses.
  • Document all orders as soon as they are received; orders should be combined whenever possible in order to generate the fewest number of physician verbal orders requiring signatures.
  • Report to a supervisor all new diagnoses, exacerbations of diagnoses, and patient transfers to inpatient facilities.

Scheduling, Post-SOC

All agency visits and outside appointments should be plotted on the patient calendar. Schedulers should watch for cancelled and missed visits and make sure they have been rescheduled whenever possible.

Clerical, Post-SOC

Clerical oversight is critical throughout every 30-day period of care. Clerical staff need to monitor and ensure that:

  • The F2F signature has been obtained (this is required by final billing).
    • While it may have been fine to hold off on the F2F signature under a 60-day billing cycle, it is definitely not a good idea under PDGM, with only 30 days from RAP to final bill!
  • Orders are sent to MDs on a daily basis
  • MD signatures are being signed within one week.
  • Any orders that haven’t been signed after a week are re-sent.
    • A 30-day response time for physician orders is no longer acceptable! 
  • The agency is following up (in phone or in person) on all physician orders that are outstanding after two weeks.
    • Consider sending your marketer (ie., your physician liaison or whoever calls on your referral sources) to obtain the physician’s signature; people who have a relationship with the physician/office may be best able to communicate the new urgency under PDGM.

Keys to Success

HHAs need to actively manage each patient throughout the entire revenue cycle, from intake through discharge, in order to ensure accurate and timely reimbursement under PDGM. Supervisors need to take the lead in interdisciplinary planning and review, but revenue cycle management must be a team approach.

Here are a few things to keep in mind as you gear up for January 1st:

  1. Assess agency policies and procedures with the new PDGM billing cycles in mind. If you haven’t started this already, do it NOW! Speed and efficiency are critical, particularly through the first five days of care.
    • Review all processes and time requirements that are critical to success under PDGM 
    • Determine which processes and protocols are helping and which ones are slowing down the process (ie: are there too many levels of approval?)
    • Assess where bottlenecks in workflow are happening, and where they are likely to happen under PDGM. Be sure you have enough staff in the correct positions to accommodate new PDGM workflows. 
    • Make sure QA staffing is at the right level for your agency’s average patient admissions/day. Industry standards state that an auditor should be able to complete 13 audits in an 8-hour day. 

2. Educate agency staff, from intake and clerical through clinical and QA.

    • Explain the necessary changes in documentation time and the need for close management of all agency patients. 
    • Make sure your clinicians know about the new 30-day billing period and understand that timely RAP submission—and timely reimbursement—is dependent on their adherence to new procedures and protocols.

3. Communicate! Timely communication and response will help to ensure timely RAP submission.

    • Encourage all staff to communicate all questions or concerns regarding any clinical, QA, or clerical processes.
    • Make communication a top priority, especially during the first few days of the billing period; all questions and concerns should be messaged directly to the clinician, QA, or supervisor.

4. Under PDGM, one RAP and one final bill must be submitted for each 30-day billing period.

5. PDGM will eliminate therapy volume as a determinant of payment.

6. The plan of care must be documented immediately after completion of the OASIS assessment; it should be as complete as possible, as soon as possible.

    • Every diagnosis a clinician documents must be addressed on the POC.
    • As many orders as possible should be documented on the POC, to cut down on the number of outstanding orders requiring MD signatures.

7. Clinicians, auditors and billers will need to know the LUPA threshold for each patient in order to optimize the plan of care and visit schedule. 

    • HHAs are used to a four-visit LUPA threshold over 60 days for every patient. Under PDGM, that will be the minimum threshold; agencies will be facing thresholds of up to 12 visits over 60 days for some HHRGs. 
    • In order to avoid LUPA and receive full payment, visits will need to be spread out for patients who are close to the new LUPA thresholds. 
    • CMS assumes that agencies will add one to two extras visits per 30-day billing period to avoid LUPA for these patients.

8. A certified coder will be more of a necessity than ever before under PDGM. Selecting the appropriate diagnoses, in the appropriate order, is essential to accurate and optimal reimbursement.

NDoc Will Help Keep Agencies On Track!

With NDoc, agencies will have access to new and revamped reports designed to help them better manage PDGM’s new 30-day revenue cycles. NDoc reports will include new protocols to help clinicians focus on charting for secondary diagnoses, and reports to help with the management of LUPAs by warning which patients are near the end of their billing periods.

NDoc agencies can use the Analytics Dashboard daily to help identify any workflow bottlenecks and actively manage RAP and billing cycle requirements. NDoc Analytics can also help agencies to assess, review, and revise procedures in order to optimize reimbursement under PDGM.

Use the Analytics Dashboard (Analytics Dashboard>Document Details>) to review:

  • Documents by Hold Reason (see what documents are on hold and for what reason) 
  • Documents Ready for Review
  • Documents Ready for Coding (if separate coder is used)

Use the Document Tracking Report (Operations>Document Management>Document Tracking) to: 

  • Identify any orders that have not been signed after a week
  • Identify any POCs that are awaiting signature 
  • Identify any F2Fs that are awaiting signature

Use the PDGM evaluator (Administration>Patient>PDGM Evaluator) to review and evaluate selected patient diagnoses.

Use NDoc Billing Reports (Operations>Patient>Billing Management)  to identify anything outstanding for RAP or final billing: 

  • OASIS exported
  • POC printed
  • First billable visit exported
  • MD enrolled in PECOS 
  • POC signed
  • Visits complete and exported
  • F2F signed
  • All physician orders (POF/PVC) signed

NDoc agencies should be sure to check their system settings to:

  • Ensure the flow of data from Intake to Referral  (Administration>System>Settings> OASIS)
  • Remove the requirement of a F2F signature for RAP submission  (Administration>System>Settings>Billing)

Don’t forget to check if there are any NDoc interfaces that can help with your PDGM procedures: SHP, SFax, CCDA.