Optimize Your Revenue Cycle for PDGM SuccessJune 4, 2019

Welcome

● Introductions & format

● PDGM summary

● Revenue cycle Impact

● Preparing for PDGM

● Workflow and technology processes

● Questions

• Use the Questions section on the GoToWebinar panel to submit questions

• Webinar will be recorded and a link to the recording will be emailed to all registrants.

Webinar Format

PDGM Summary

Annie ErstlingChief Strategy Officer

Erin MastersonConsulting Manager

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Patient Driven Groupings Model (PDGM)

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● PPS:○ 60-day episode with four

or fewer total visits are paid per visit

● PDGM: ○ LUPAs now have variable

thresholds based on HHRG

○ Different level for each of the 432 HHRGs

○ 10th percentile value of visits for each threshold

○ LUPA Add-on remains

LUPAs

Billing● For billing purposes, PDGM proposes to keep the RAP/final claim billing methodology

○ CMS estimates the median time to submit a RAP is 12 days so they are soliciting comments on if this makes sense

○ 5% of RAPs not submitted until after day 60

● New agencies as of 1/1/2019 would not receive RAP payments under PDGM but required to submit a “no pay” RAP○ Potential Notice of Admission in the future

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Billing● Source of admission indicated by occurrence code on the final claim only (not included on

RAPs)○ Medicare will automatically adjust claim if community is indicated but an institutional

source submits Medicare claim

● Clinical Groupings and Comorbidity Adjustment based on diagnoses on the CLAIM, not the OASIS○ Up to 25 diagnosis codes can go on claim compared to 6 on OASIS

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Miscellaneous● OASIS still completed every 60 days ● PEPs (Partial Episode Payments) have same methodology● Outliers have same methodology, although fixed dollar loss would need to change

○ Based on current rules, 4.77% of estimated total payments would be outlier dollars○ CMS requirement that number cannot exceed 2.5%

● Non Routine Supply (NRS) Add-on payments eliminated

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Revenue Cycle Impact

General● Educate all staff● Establish strong interdepartmental communication● Develop reporting on key indicators driving reimbursement under PDGM● Establish internal PDGM steering committee

Key Metrics to Monitor:● Productivity levels for all departments● Staffing levels required to implement optimal workflows under PDGM

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Marketing● Understand the impact of your primary referral source● Analyze current marketing and referral relations strategies

○ Includes education to referral sources● Determine what a “good” referral is in the future

Key Metrics to Monitor:● Admission Percentage● Most common clinical groupings referred by each referral source

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Intake● Obtain as much information as possible at time of referral

○ This will be vital in supporting coders● Strong communication with Scheduling Department● Minimize gaps in entry of referral information into EMR

○ Develop Intake checklist

Key Metrics to Monitor:● Productivity ● Early/Late Percentage● Community/Institutional Percentage

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Case Management● Interdisciplinary communication

○ Therapy still plays an important role in the care plan● LUPA management under new structure

○ Early identification of HIPPS allows for more effective LUPA management● Continuing assessment of patient during care

○ ROC assessment/SCIC will change HIPPS under PDGM● Supply management

Key Metrics to Monitor:● Turnaround time for OASIS completion/submission to CMS● LUPA percentage ● Average length of stay● Periods per patient

● Periods per patient15

Coding● Accurate and complete coding is essential● Will determine Clinical Grouping and Comorbidity Adjustment● Include all pertinent diagnoses

○ Up to 25 diagnosis fields available on claim; all of these will be considered when determining comorbidity adjustment

● Be aware of diagnoses that would be considered Questionable Encounters● If significant change in condition occurs, coding may need to be updated

Key Metrics to Monitor:● Current - what percentage of periods would fall under a QE status?● Average number of diagnoses per claim● Comorbidity percentage – no, low, high● Days to RAP

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● Shorter billing period makes quick turnaround on signed orders even more important● Timely receipt of F2F documentation also more important● What is order submission process?● Determine if current frequency/method of follow-up with physicians is efficient● Education to physicians

Key Metrics to Monitor:● Average days after start of episode that 485 is sent to physician● Volume of interim orders generated after start of episode● Average turnaround time for receipt of signed physician orders

Orders Tracking

Billing● Volume of claims increases● Shorter timeframe to resolve all pre-billing issues prior to final claim● Monitor claims to identify Medicare processing errors● Future of RAPs is uncertain● Communication with coders on QE

Key Metrics to Monitor:● Days to RAP/Final Claim● Frequency of billing● Claim volume on outstanding accounts receivable● Volume of unbilled claims

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Changes in Claim Management● CMS will calculate reimbursement based on prior claims in common working file (CWF),

diagnoses/visits on submitted claim and OASIS in QIES system, not HIPPS listed on claim○ Need to investigate all remaining balances on A/R prior to adjusting off in EMR○ Pricer not implemented until 1/6/2020

● Occurrence Codes for institutional referral sources○ OC 61 – acute inpatient hospital stay○ OC 62 – SNF, IRF, LTCH, IPF

● Occurrence Code 50 indicates assessment date

● Treatment authorization code no longer required on claims

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Preparing for PDGM

Checklist● Educate entire staff● Determine estimated revenue impact

○ Agency-level detail available on CMS website under “Home Health Agency (HHA) Center” provider section

○ Download PDGM grouper○ Limited Data Set (LDS) made available by CMS

● Evaluate current agency data for key PDGM indicators ● Perform coding/OASIS audit

○ Identify potential impact of QE, comorbidities, etc.● Evaluate current processes and workflows

○ Are these sustainable under PDGM?

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Leverage Industry Resources● National, state organizations, and other advocacy groups

○ Attend workshops, seminars, and webinars ○ Subscribe to written publications and listservs

● There are expert organizations that can assist providers with preparation

● Consulting groups have purchased Limited Data Set (LDS) from CMS

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Workflow Processes & Technology

Process & Technology● Success depends on people, process & technology alignment

● Review your internal processes, evaluate your teams and resources & seek out best in breed technology solutions

● Work directly with your EHR or ancillary technology companies to determine PDGM specific enhancements○ What new functionality/reporting will be made available?○ When will these new features be released for testing?○ Will your current workflows still be viable after updates made?

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PATIENT

Referrals & Intake

Clinical Care

Quality

Data & Analytics

Finance &Rev Cycle ● Improved communication and

collaboration between cross-functional teams

● Accurate & consistent wound measurements

● Seamless integration with EHR

● Evaluate referral sources● Streamline intake process● Ensure accurate and complete

intake information● Turn intake documents into

actionable data

● Support timely and expedited billing with clear documentation and processes

● Timely receipt of signed and dated orders, plan of care and F2F

● Obtain electronic signatures

● Evaluate and optimize internal processes with real-time productivity and efficiency insights

● Data model for agency specific PDGM assessment

● Predictive revenue trending

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● Support timely and expedited billing with clear documentation & processes

● Timely receipt of signed & dated orders, plan of care & F2F

Questions? Erin Masterson

Consulting ManagerErinMasterson@BlackTreeHealthcare.com

(610) 536-6005 ext. 712

Annie ErstlingChief Strategy Officer

aerstling@forcura.com(904) 707-2902