Blunting Major Concerns with PDGM

Netsmart is advocating for passage of the Home Health Payment Innovation Act of 2019 (S. 433/H.R. 2573). This legislation addresses major concerns with the Patient Driven Groupings Model (PDGM), a completely new payment model for home health services effective January 1, 2020.

Among other provisions, this legislation would require the Centers for Medicare and Medicaid Services (CMS) to use actual changes in provider behavior based on claims and other data after PDGM is implemented (instead of assumed behavior) as the basis for payment changes to providers under PDGM. The bills also reinforce the need for any new model to be budget neutral and limit an agency’s losses or gains to 2% per year.

On October 31, CMS published its CY 2020 Home Health Prospective Payment System (HH PPS) Final Rule. While it lowers the first-year PDGM base rate reduction for home health providers from 8.01% to 4.36%, it is still based on assumptions of provider behavior under the new payment system. It is also still a significant reduction in Medicare Home Health Program payments, likely to cause instability to providers, threaten access to care and harm the Medicare home health program for seniors.

The bills have been referred to the House Ways & Means and Energy & Commerce Committees, and the Senate Finance Committee. One potential path is to attach the legislation to a year-end “extender” bill that renews or extends other programs.

Netsmart advocacy on this issue includes collaboration with the Partnership for Quality Home Health Care and the National Association for Home Care & Hospice (NAHC), and meetings with CMS.

More Information:

Bill text

Partnership for Quality Home Healthcare letter to CMS

Discharge Planning Final Rule

CMS delivered the long-awaited final rule for Discharge Planning requirements for Hospitals, Critical Access Hospitals, and Home Health providers. These requirements are effective November 29, 2019, sixty days after the final rule was published. 

CMS finalized less a restrictive rule which requires a transmission of "medically relevant" data to the next provider of care, allowing the provider to determine the data elements and mode of transmission. While they do not require the use of CEHRT they are encouraging the use of electronic transmissions of data for providers who can send and those who can receive the data.  Netsmart has solutions to facilitate data transfers, contact your CAE for more information.

Medicare Advantage and PDGM

The CMS Medicare Payment Plan Group released a memo describing the regulatory obligations the Medicare Advantage (MA) plans are under to provide the HIPPS codes to the Medicare Advantage Encounter Data System (EDS) for Skilled Nursing Facility (SNF) and Home Health (HH) episodes of care.

CMS regulations from 2014 directed MA plans to provide the HIPPS codes derived from the OBRA-required comprehensive assessment for SNF encounters and the OASIS start of care assessment for HH encounters to EDS system.

This is accomplished by placing the appropriate HIPPS code, developed from the grouper, on the MA claim.  CMS is allowing the MA plans the “maximum flexibility” in their reimbursement strategies by allowing either the pre-PDPM/pre-PDGM HIPPS codes or the PDPM/PDGM HIPPS codes to be used by the MA plans. 

Impact to providers:

  • SNF providers will use the 2019 OBRA assessment to obtain the pre-PDPM code
  • HHAs are required to use OASIS D1 assessments for episodes of care starting 1/1/2020.  Some of the data elements required for pre-PDGM HIPPS code development are now considered "optional" which an create a challenge if HHAs decide not to complete those data elements.

Netsmart is developing its own grouper to process pre-PDGM HIPPS codes. Please stay tuned for more information before the end of 2019.

In the meantime, continue to reach out to your MA plans to determine if they plan to transition to the new PDGM HIPPS reporting.

Review Choices Update to Texas

On 10/21/2019, CMS announced a delay of the Review Choice Demonstration (RCD) for Texas, North Carolina and Florida until later in 2020, allowing for implementation of the PDGM on January 1, 2020. The RCD is expected to begin for Texas on March 2, 2020, with the selection period to begin January 15, 2020 and end on February 13, 2020. The next two states, North Carolina and Florida, are expected to begin May 4, 2020. This announcement also includes a notice that LUPAs will be included within the RCD as the industry transitions to PDGM.

For further information, please review the CMS Review Choice Demonstration webpage.

Medicare Beneficiary Identifier 

REMINDER … the Medicare Beneficiary Identifier (MBI) is required on all Medicare claims submitted beginning 1/1/2020, regardless of the dates of service. Claims with a Health Insurance Claim Number (HICN) will be rejected, and eligibility inquiries with the HICN will be rejected. 

Ensure you are getting the patient MBI from their new Medicare cards or you can use your Medicare Administrative Contractor (MAC) look-up tool. You will need to sign up for the Portal to use your MAC’s tool. Sign up now to avoid future delays.

October OASIS Q&A's have been posted