Why Home Health Agencies Should Pump the Brakes on Their PDGM Preparation

While it’s important to prepare for the Patient-Driven Groupings Model (PDGM) in 2020, home health owners and operators need to make sure they’re not taking their eye off the ball in 2019.

The Prospective Payment System (PPS) is complex enough, so being overly focused on the future could impact financial success in the present.

That’s according to Tom Maxwell, co-founder and co-CEO of Maxwell Healthcare Associates, a home health and hospice consulting firm that specializes in EMR implementations and optimizations, along with other services.

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Home Health Care News recently caught up with Maxwell to hear his take on where agencies should be on their PDGM checklist. In addition to PDGM, Maxwell also shared his thoughts on a potential phase out of Requests for Anticipated Payments (RAPs).

Highlights from HHCN’s conversation with Maxwell are below, edited for length and clarity.

HHCN: We’ve seen a lot of urgency around PDGM. But you have kind of a different view on where agencies should be in terms of preparation. Can you elaborate?

Maxwell: We have a few months before we really have to jump deep into PDGM. I think everybody should be in the planning phase and the analysis phase. If you look at the different puzzle pieces that are coming, you have to have a sense of where you’re at and where you’re going to be.

But one of the things we spend a lot of time at Maxwell doing is just-in-time training. If I go out and train all of my clinicians on the new model of LUPA today — here in August — then that’s going to impact what they learn, what they know and how much they retain come Jan. 1, 2020. You don’t want to get lost in the weeds just yet.

If my team starts changing their coding and documentation behavior today because of PDGM, that’s not going to impact the third quarter and fourth quarter very well under PPS. In fact, it’s going to have a very negative impact on the third quarter and fourth quarter.

What’s your advice on where agencies should be right now then? And what are you seeing with your clients?

I think the message that we’ve kind of come up with is that we have to “get ready to go.” We have to prepare and plan. But if you really start teaching everybody in August, the retention of that information is going to be very low.

We think you need to come up with a late-November or early-December training plan. That’s when you, for example, start bringing in experts to figure out what kind of documentation is needed to code co-morbid claims or to get ready for the new LUPA model.

I think if everybody scrambles and does that in August and September, we’re going to have to re-learn things in January, February and March.

I see a lot of companies that are scrambling now, bringing their staff in and really ramping up training on the new models out there. I just think that’s going to cause pain and behavior changes [when] you really don’t want to.

You can start reviewing that clinical documentation and making sure your clinicians have an easy, capable way of documenting co-morbid diagnoses of every single patient.

If I have 10,000 clinicians, how do I get them ready for the new LUPA model or the new orders model without hindering operations today?

We’ve seen a lot of people who start training today just end up confusing their clinicians. A lot of people are backing off a bit and looking at that November and December timeline.

What are some of your other concerns around PDGM implementation?

The other thing I’ve been talking to people about a lot is that this is a major shift not just for the home health agencies, but also for the fiscal intermediaries. UGS, Palmetto — all those different guys out there — are they going to be ready? And what’s the impact going to be for them?

We saw what could happen when pre-claim came out. We just overwhelmed Palmetto in Illinois.

I think we really have to be prepared from a financial perspective. We need to know how long we can survive without things processing appropriately. And we need to have a fallback plan. What happens if they’re not ready? Or what happens if the government realizes they’re not ready and wants to delay or change [PDGM]?

I don’t necessarily think that’ll happen, but you need to have a fall-back plan for every scenario. How do we turn everything off that we just built? I think agencies need to be prepared for that.

What else?

I think another big shift in mindset is going to be documenting that care plan so you’re appropriately seeing that patient in a 30-day episode, not causing yourself to be in a LUPA situation. We’ve had LUPAs for a better part of 20 years now that have been the same. Everybody understands that, but now you have to go re-learn all that.

Coding appropriately now that there are 432 case-mix groups is going to be big. But it isn’t all about coding; we’ll need to be documenting appropriately so when we do code our patients, we have that supporting documentation there.

We’re going to have to retrain the mindset of all these workers, especially start-of-care nurses going out and doing that OASIS visit.

In the back office, there will be lots of hurdles to clear around billing and the new 30-day cycles, collection of orders.

Lots of people have talked about how you’ll need to increase your billing staff. I think some of that’s true, but I think you have to become way more efficient ultimately. Your billing staff needs to be confident in the technology or systems they’re using.

We hear a lot of negatives about PDGM, namely the model’s assumption-based behavioral adjustment that could pose a more than 8% cut to providers. Are there any things you’re excited about or looking forward to?

It all seems to be doom and gloom around PDGM in the industry. But I do think it’s an opportunity for those agencies that are sophisticated. If you can change and adjust, you’re going to excel. Agencies that have always been doing the right thing from a therapy documentation standpoint or clinical documentation standpoint, they’re going to excel.

There’s just going to be a re-education for the entire industry, which means an opportunity for everybody to get on the same playing field. That’s a positive in my opinion.

How do we do our jobs better and faster? How do we get patients to heal quicker or accept the rehab we’re providing them? That’s the goal here. That’s the reason Medicare is making a change. The goal is to be as efficient as possible with the home health spend of Medicare dollars.

Apart from PDGM, CMS also floated a phase out of RAPs in its July 11 proposed rule. What impact would that have in your estimation?

I think that’s going to be painful to the small agency that doesn’t have enough cash in the bank to support a potential phase out. Historically, I think a lot of home health agencies have used that RAP payment to help finance care. If that goes away, it’s going to be a serious challenge.

I think for some of the bigger agencies that have the cash flow and reserves on hand, they’re going to be able to survive that. But I truly believe the smaller agencies providing care to rural patients in the industry are going to struggle.

They need to start thinking about how they’ll absorb that. It scares me a bit for the little guys.

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