The switch to the Patient-Driven Groupings Model (PDGM) was always going to be a hurdle for home health agencies, but the onset of the COVID-19 crisis has exacerbated the woes associated with it.
For instance, managing 30-day billing periods and avoiding low-utilization payment adjustments (LUPAs) have been pain points for providers across the country over the last year or so.
An analysis from McBee Associates of claims data from Q1 and Q2 of 2020 shows that these problems can be avoided with a stronger attention to detail, however.
Almost 70% of subsequent 30-day period LUPAs had only one visit made during the period in Q1 and Q2 of 2020. About 85% of LUPAs in subsequent 30-day periods were only one visit short of the threshold to avoid a LUPA.
“One visit in a period is always going to be a LUPA, and we know that the majority of subsequent periods have a really low LUPA threshold of only two or three, so that’s pretty significant,” Carissa McKenna, the senior clinical consulting manager at McBee Associates, said on a webinar Tuesday. “Almost 85% of the subsequent period LUPAs are only one visit short of meeting that LUPA threshold, meaning one more visit made within that period would have resulted in a full period payment, rather than a LUPA.”
Wayne, Pennsylvania-based McBee Associates is a health care services and consulting firm that offers financial, operational and clinical help to health care providers across the continuum.
Its analysis of the data found that the most common clinical groupings that resulted in LUPAs were complex, such as catheter and ostomy patients. After that were surgical and infectious disease patients being cared for, which isn’t necessarily intuitive, McKenna said.
“We wouldn’t expect those secondary ones to be at a higher LUPA risk. We would expect these to be high-risk patients that require additional visits into the subsequent period,” McKenna said. “So we really would want to be focusing on those patients to find out what’s going on that is creating those [problems] in the subsequent periods for those patients.”
Subsequent period LUPA patients were more likely to have high co-morbidity adjustments and also high functional impairment levels.
Still, providers are only missing that threshold by one visit, so honing in on these periods and these patients moving forward will help claw some of that money back.
Managing operations to mitigate LUPAs
The first goal to avoid LUPAs should be simple: recognizing the period start and end dates for each patient.
The 30-day periods have clearly changed things for home health providers, so keeping track of where visits are being dispersed among the billing periods can be paramount to success.
“One of the most common issues that we’re seeing right now is overutilization in the first 30 days — a lot of visits in those first 30 days, followed by underutilization in the subsequent 30-day period,” McKenna said. “Clinicians are often not scheduling out through the entire 60 days, which results in poor tracking of the payment periods and billing periods. It’s really critical to know when one 30-day period ends and the next one begins, because simply moving a visit from one day to the next day under PDGM can mean moving a visit from the first 30-day payment period to the subsequent 30-day payment period.”
Moving a visit from one day to the next, which may even be the discharge visit, could mean that you have a one-visit LUPA during that period.
Providers should be able to locate this in their EMR and data through the patient calendar and the scheduler’s calendar. There are other places to find it as well, but it can be found pretty easily by calculating 30 days from the start of care date.
Knowing certain LUPA thresholds for patients should also be a priority, and can also be found through EMR or a patient’s HIPPS code, as should the patient’s clinical grouping and primary focus of care. In other words, agencies should be aware of why exactly this patient is receiving home health services and make sure their visits line up with that.
For patients that are functionally impaired, that’s when an agency can step in and potentially provide some therapy visits. That way, the patient is being cared for like they should — and the agency is also less likely to meet that threshold to avoid the LUPA.
“Episode management is also key as is the knowledge of the disciplines that have been referred or that are already involved in the patient’s care,” McKenna said. “This tells us who we expect to be involved in the care plan. It helps us to improve coordination across the care team. It prevents overwhelming the patient with too many visits on one day or even within one week.”
In the end, agencies need to be on their cues in order to optimize workflow in 30-day periods and avoid LUPAs.
Patients should be tracked fastidiously and missed visits should be easily recognizable and immediately rectified so those visits are made up and also not spilling over into another period, and thus triggering LUPAs.