Physician Education Likely to Pose Major Challenge Under PDGM

When it comes to the Patient-Driven Groupings Model (PDGM) and common concerns, most home health providers are quick to cite the overhaul’s widely opposed behavioral adjustments or controversial changes to therapy reimbursement.

Although those two points are certainly important, PDGM also brings several lesser talked about, hidden challenges to the table as well. At the very top of the list is physician education.

“Physician education is one of the things that worries me most [about PDGM],” April Anthony, CEO of Encompass Health Corporation’s (NYSE: EHC) home health and hospice division, recently said at the 2019 Home Health Care News Summit in Chicago.


Even today under the Prospective Payment System (PPS), interactions between home health providers and physicians are too frequently filled with communication gaps and misunderstandings — and the current PPS model has been in effect since Oct. 1, 1990. More issues are bound to increase with the emergence of a new payment mechanism, especially one as complex as PDGM.

Overall, PDGM comes with 432 case-mix groups determined by admission source, timing, clinical grouping, functional impairment and co-morbidity adjustment.

And submitting claims with primary diagnoses that don’t fit into one of PDGM’s 12 clinical groupings — or questionable encounters — will be particularly troubling for many providers.


Moving forward, questionable encounter claims will be sent back to agencies as “returned to provider,” meaning agencies will have to review their paperwork and send in updated claims with a more appropriate diagnosis that better matches PDGM’s framework.

“Generalized muscle weakness” is, perhaps, the most common example of a questionable encounter.

Making sure referring physicians understand PDGM’s nuances and are aware of the different questionable encounters should be a major focus for home health providers in the remainder of 2019.

Encompass Health has already taken those steps, Anthony told summit attendees.

Based in Birmingham, Alabama, Encompass Health offers both facility- and home-based patient care in 37 states through its network of 133 hospitals, 245 home health agencies and 82 hospice locations home health agencies and hospice agencies.

“We’re not waiting until [questionable encounters] happen in January to educate that physician,” Anthony said. “We’re educating them right now about why that code doesn’t really work in [home health], why you need to get a little bit more specificity.”

In its final payment rule released last year, the Centers for Medicare & Medicaid Services (CMS) estimated that about 15% of PDGM’s 30-day payment period could be classified as questionable encounters based on current trends. 

“I think [CMS] has not done its part in meeting its obligation to educate the physician community about why they’re going to have to behave differently in home health,” Anthony said. “We’re going to have to do that.”

Several other providers have echoed that point to HHCN in the past, including Masonicare Home Health and Hospice.

Wallingford, Connecticut-based Masonicare is a not-for-profit health continuum that offers home health and hospice, among other services. Masonicare has six offices and operates one of the largest nursing homes in Connecticut. 

“I think it would be helpful if physicians and physicians practices had some education from CMS, which hasn’t always been the case,” Susan Adams, vice president and administrator at Masonicare Home Health and Hospice, previously told HHCN. “So, for instance, CMS may make a ruling that seriously impacts home health providers but it involves physician alignment and CMS has not been able to step up and ensure the physician understands their potential new role.”

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