Home Health LUPA Challenges Continue as Pandemic Subsides

The frequency of low-utilization payment adjustments (LUPAs) increased for many home health providers in the first year of the Patient-Driven Groupings Model (PDGM), which coincided with the COVID-19 crisis.

In part, that’s because there are far more LUPA variables to keep track of under the new payment model. At times, increases were also linked to home health patients unexpectedly declining scheduled visits because of COVID-19 fears.

To some, avoiding LUPAs by hitting a certain visit threshold may seem like a relatively simple process. But home health providers in the weeds are telling a different story.


“It’s probably one of the bigger challenges under PDGM,” Nick Seabrook, the managing director of BlackTree Healthcare Consulting, told Home Health Care News. “Under the Prospective Payment System (PPS), we had a single threshold. We had to manage five visits, and it was over 60 days. Now, you have 432 thresholds to try to manage, and it’s over 30 days. I think those two factors are what’s really driving LUPAs up.”

King of Prussia, Pennsylvania-based BlackTree Healthcare Consulting provides billing, OASIS and other services to home health agencies, among other post-acute care providers.

Home health companies were concerned about LUPAs prior to the onset of PDGM, whereas the Centers for Medicare & Medicaid Services (CMS) actually thought they’d be less of an issue.


“One of the components of that behavioral adjustment was the assumption that we were going to get better at LUPA management,” Seabrook said. “But I think that was a short-sighted view on their end, just knowing that it’s more sophisticated now than it was before.”

EvergreenHealth Home Care, a hospital-based home health and hospice provider in Washington state, was hit hard by LUPA struggles in 2020. It was one of the first providers in the country to treat COVID-19 patients, with the pandemic exacerbating PDGM’s pain points.

Brent Korte, the chief home care officer for EvergreenHealth, expects the issue to continuously improve as time passes. But the struggles have taught both him and his organization about what’s needed to prevent LUPAs.

“You need an up-to-the-minute understanding of where each patient lines up with LUPAs,” Korte told HHCN. “And we didn’t have that, and that was really disarming. It caused a lot of extra work on our part, generally as an organization. I think we’ve learned a ton from it. Hopefully, we’re going to bounce into the rest of 2021 with a lot more focus on actually tackling PDGM versus being distracted only by the pandemic.”

Not just a distraction

The pandemic hasn’t just been a distraction from regular home health challenges. It has had tangible effects on LUPAs.

Sudden hospitalizations due to unplanned complications, staffing shortages tied to quarantine protocols and canceled visits because of patients’ anxieties can all throw an organization’s LUPA-mitigation efforts out of whack.

If a missed visit is on a Tuesday, for instance, even making up for it immediately the next day could lead to a LUPA in the new 30-day periods. Additionally, access to patients in facilities was also a challenge in 2020, which made the scheduling process more difficult.

“If we can’t see a patient on one day, and we have to go in on the next, it could trigger a LUPA, and that’s been enormously [challenging],” Korte said. “Our case loads have also grown, which means our nurses and physical therapists, in particular, have had to [do more]. In the meantime, the pandemic has caused a deluge of significantly more acute patients, patients who would otherwise have been admitted to skilled nursing facilities.”

To Seabrook’s point, the behavioral adjustment from CMS did not reflect the reality that set in for EvergreenHealth, as well as other providers across the country. The adjustment was a proactive move on the agency’s part — not reactive.

“We would have preferred that CMS, in one regard, be reactive versus proactive in trying to alter our compensation,” Korte said. “I think for some providers, that behavioral adjustment in and of itself caused a behavioral adjustment.”

Given the current acuity of its home health patients, EvergreenHealth hopes to lower its LUPA rate into the single digits by the end of this year.

“If we can meet our patients’ needs, knowing how sick they are through the pandemic and how we’ve had such an increase in acuity in the last 14 months, being in the single digits for LUPAs would be a great goal to reach,” Korte said.

Finding what works

As far as what’s worked, educating each clinician on LUPAs has kept EvergreenHealth’s head above water.

It’s one thing for an agency’s leaders to understand what triggers LUPAs and how to fix them, but without top-down continuity, things can fall through the cracks operationally.

“What really works is making sure that clinicians understand their impact and understand the coordination that it takes,” Molly McDonald, the clinical quality coordinator for EvergreenHealth’s home health and hospice business, told HHCN. “It’s more than the one time when the patient comes on service, trying to plan that out. It takes constant re-coordinating.”

In certain instances, a provider won’t know what a patient’s HIPPS code is until 10 days in, which is now a third of the way into the period, Seabrook said.

“After a provider goes through their regular QA process and OASIS is completed, then the quality staff is reviewing the OASIS,” Seabrook said. “They’re providing their feedback to the clinician, the clinician makes their change, and now they lock the OASIS in and you have that HIPPS code. You’re looking at that potentially 10 days into the period, and that HIPPS code is going to determine what that LUPA threshold is. You’re a third of the way into a period before you finally find out that threshold.”

COVID-19 is still affecting the LUPA problem throughout the home health sector. As the crisis subsides, so will some of the pain that comes with PDGM woes.

Still, LUPA management will continue to require diligence for providers to bolster their bottom lines.

“The problem will get better,” McDonald said. “But we’re still emphasizing everything that we did when it comes to the COVID overlay of this and the importance of continued PPE, infection control and vaccination pushes. This allows us to continue to see patients in their home and in facilities. If we don’t, that still is a real problem when it comes to the LUPAs.”

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