Industry Awaits Verdict on PDGM’s Behavioral Adjustments After Arguing Case to CMS

Now that the comment period for the proposed 2020 home health payment rule from the Centers for Medicare & Medicaid Services (CMS) has closed, providers are left waiting to see how things shake out.

By far, the most frequently requested change by providers and trade groups alike is the elimination of the Patient-Driven Grouping Model’s (PDGM) behavioral assumptions. From high-powered CEOs to lawmakers on Capitol Hill, most everyone seems to be asking whether CMS will abandon its notion that agencies will automatically choose the reimbursement codes with the highest payout under PDGM and always carry out enough visits to avoid LUPA claims.

LeadingAge, the Partnership for Quality Home Healthcare (PQHH) and the National Association for Home Care & Hospice (NAHC) are among those in the anti-adjustment camp. The trade groups shared their proposed payment rule comments with Home Health Care News following the CMS submission deadline. 


“We strongly oppose the prospective application of behavior assumptions on CY 2020 payment rates,” LeadingAge wrote. “The degree to which CMS is assuming the three behavioral changes by providers due to the PDGM proposal takes an unnecessarily cynical view of home health agencies.”

PDGM and its 432 case-mix groupings create a significantly more complex framework for coding. Despite the change, CMS assumes agencies will automatically choose and know to use the reimbursement codes associated with the highest payout, a process referred to as “upcoding.”

This could lead to a reimbursement cut of more than 8.01% — a troubling detail LeadingAge, PQHH and NAHC stressed. 


“At a time when there is transition to a new payment system and there is a lack of transparency on the underlying assumptions, we are asking that CMS reconsider the 8.01% reduction in payment that is based on perceived changes that may occur when PDGM is implemented rather than on actual data from the payment years, as in the past behavioral assumptions,” PQHH wrote. “We believe that these assumptions lack a solid foundation, are over-stated and will jeopardize patient care.”

PQHH went on to suggest a longer implementation window for reductions, proposing a period of 10 years “so that there is not a dramatic effect on access to care and so that CMS can adequately assess the impact of these assumptions during a phased-in period of time.” 

Meanwhile, NAHC pointed out that the industry still doesn’t have an accurate picture of what behavioral assumptions would look like if implemented.

“We do not believe we have been afforded an adequate ‘description’ of the behavior adjustment to fully comment on the assumptions made to support the proposed adjustment,” NAHC said in its comment to CMS. “Instead, the notice of proposed rulemaking contains a summary description with the needed details absent both in terms of the rational for the assumptions made and the calculations made using those assumptions.”

Beyond behavioral assumptions

The industry is less uniform in terms of support and opposition to other items in the proposed rule, if the comments to CMS are any indication.

For example, while dozens of therapists commented on their support of the phase out of Requests for Anticipated Payments (RAPs), smaller agencies and groups representing them expressed fear the elimination of pre-payments would put them out of business.

“Within nonprofit providers, particularly smaller organizations, cash flow can still be an issue if RAP payments were to go away,” LeadingAge wrote. “While we are supportive of measures to ensure program integrity broadly, not all organizations that request RAP payments are fraudulent.”

NAHC also advised CMS to withdraw its proposed termination of RAPs and change its proposed notice of admission (NOA) requirements. NOA is currently set to replace RAPs.

“Since the NOA does not generate a payment and only serves to update the common working file, it is unnecessary for CMS to require agencies to have the same requirements for the NOA submission as for the RAP submission,” NAHC wrote. “Further, experiences with RAP submissions indicate that HHAs will not likely be able to meet the 5 day time frame for submission of the NOA if agencies must comply with all of the proposed requirements.”

In contrast, many large home health providers have seemingly embraced a possible phase out of RAPs because of the M&A opportunities that would likely pop up. 

LeadingAge also expressed their opposition to the removal of pain measures from the Home Health Care Quality Reporting Program (HH QRP) and the Home Health Care Consumer Assessment of Health care Providers and Systems Survey (HHCAHPS).

Meanwhile, PQHH made it a priority to tell CMS about the group’s concerns surrounding the elimination of certain diagnosis codes, PDGM’s impact on the availability of therapy services and the new model’s Jan. 1 2020 implementation date. 

Finally, NAHC argued CMS should issue a draft of the HH QRP assessment tool six months prior to implementation. The association also asked that CMS not require the OASIS data set be collected on all patients served by the agency regardless of payer and for CMS to tweak the proposed home infusion therapy benefit.

Companies featured in this article: