Mythbusting Alternative Payment Models

As new incentives and alternative payment systems continue to come into effect, home health agencies need to make sense of rumors on their impacts and understand how best to navigate the new landscape.

Value based purchasing and the Pre-Claim Review Demonstration from the Centers for Medicare & Medicaid Services (CMS) are taking their hits, but there are some upsides for home health agencies, as well.


There are several myths surrounding value-based purchasing and the pre-claim demonstration in terms of its impact on operations, according to Stewart Campbell, vice president of global marketing at Procura, who recently spoke about the new models in a webinar.

For one, there is a belief by some that participating in value-based purchasing models will “kill your margins immediately.” This myth, according to Campbell, is false, and health care providers participating actually have the opportunity to see they reimbursements jump 8% over time if they are in full compliance. Conversely, those that are not compliant could see their payments squeezed by 8% by 2021.

Another false claim about value-based purchasing is related to its complexities. However, “there are only a handful of process changes to follow.”

Surrounding pre-claim, there is a myth that CMS will reduce the number of claims it will accept, according to Campbell.

On the other hand, the myth that CMS is having a hard time with the demonstration in Illinois has been confirmed.

“The staff requirements are badly slowing things down, by almost a month,” Campbell said during the webinar. “They are even encouraging fax machines and manual transmission to improve this.”

Best Practices and Tips

When it comes to navigating new regulations, home health businesses that have technology that can support compliance measures will be better off, according to Campbell. To get all the pieces of the puzzle in place, agencies also must be proactive when it comes to their compliance and reporting responsibilities.

A trick to successful claims processes is also finding the right balance in documentation—reporting enough information to get approval, but not too much. Agencies need to be sure they meet the face-to-face and homeboumd status requirements in particular.

“Not too little and not too much,” Cambell said. “Checking the box doesn’t cut it anymore, but you don’t want to write the second coming of War and Peace, either.”

Written by Amy Baxter