Patient-Driven Groupings Model (PDGM)

• PDGM details

• Preparing for PDGM

• Leveraging Technology

• Use the Questions section on the

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• Webinar will be recorded and a link to the

recording will be emailed to all registrants.

Overview & Format

Craig Mandeville,CEO at Forcura

Brian Harris,Consulting Director

• Implementation date proposed to be for periods of care beginning on or after January 1, 2020

• Budget neutral – huge win compared to the estimated $950M reduction in payment of HHGM

• Replaces 60-day payment episodes with 30-day periods

• Eliminates the use of the number of therapy visits in payment determination

What is PDGM?

• Increase total number of case-mix weights from 153 to 432

• Modification to low utilization payment adjustments (LUPAs)

• Model based on claims with through dates in 2017 that were processed by March 2, 2018

– 6,771,059 episodes– 959,410 (14.2%) excluded due to non-linked OASIS– 7,458 cost reports

What is PDGM?

What is PDGM?

Patient-Driven Groupings Model

PDGM Details

• PDGM:– 30-day periods – The first 30 day period would be defined as early and all

subsequent periods would be classified as late– A 30-day period could not be considered early unless

there was a gap of more than 60 days between the end of one period and the start of another

PDGM Details

• Patients discharged from an institutional setting (inpatient hospital, SNF, IRF, LTCH, IPF) in the prior 14 days will be defined as institutional and all others as community

• Second periods with an institutional discharge within 14 days of the SOC would be considered community

PDGM Details

Institutional• 1.4 episodes per patient• Higher initial resource use

Community• 2.6 episodes per patient• Lower initial resource use• More likely to have chronic conditions, therefore more likely

to require ongoing but less resource-intensive care

PDGM Details

PDGM Details

Source and Timing Avg Reimb

Community Early $2,164.08

Institutional Early $2,483.18

Community Late $1,455.39

Institutional Late $2,239.14

Source Avg Reimb

Community $1,809.73

Institutional $2,361.16

Difference $551.43

Timing Avg Reimb

Early $2,323.63

Late $1,847.26

Difference $476.37

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PPS:• Based on clinical severity levels based on 13 OASIS assessment

itemsPDGM Final Rule:• 30-day periods are grouped into 12 clinical groups based on

principle diagnosisQuestionable Encounters:

• Nineteen percent (19%) of the 30-day periods were considered Questionable Encounters (QE)

• Updated ICD-10 diagnosis tables added ~5,000 diagnosis codes that previously were considered QE that are now not questionable (38,409 to 43,287)

• Estimated fifteen percent (15%) of periods considered QE after diagnosis update

•

PDGM Details

12

PDGM Details

PDGM Details

PPS:• Classified into 1 of 3 functional levels based on six OASIS

assessment items• Functional levels based on points:

– Low, Medium, High

PDGM:• Classified into 1 of 3 functional levels based on eight OASIS

assessment items

PDGM Details

PDGM Details

PDGM Details

Functional Level Avg Reimb Difference PercentageLow $1,835.97

Medium $2,113.72 $277.74 15.1%High $2,306.65 $192.93 9.1%

• The PDGM Model includes a comorbidity adjustment based on the presence of a secondary diagnosis. The home health specific comorbidity list includes 13 broad categories with 116 subcategories. Of those 116 subcategories, 13 are included in the comorbidity adjustment of the PDGM:

PDGM Details

• Analysis of subgroups was completed to determine which interactions (diagnoses from two subgroups) had increased resource utilization

• 343 different subgroup interactions– 187 had significant difference in resource use

• 34 had value that exceeded $150– $150 used as approximately three times the median value for the

individual subgroups

PDGM Details

Three Levels:1. No2. Low3. High

• Low - Secondary Diagnosis within one of the subgroups listed in table 30

• High - Two or more Secondary Diagnoses within the subgroups listed in table 31

*Can be only one of the above (can’t be Low AND High)

PDGM Details

PDGM Details

PDGM Details

Functional Level Avg Reimb Difference PercentageNo $1,942.63

Low $2,047.21 $104.58 5.4%High $2,266.49 $219.28 10.7%

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

PDGM Details

Visit Threshold HHRGs %

2 94 21.8%

3 128 29.6%

4 137 31.7%

5 63 14.6%

6 10 2.3%

PDGM Details

Clinical Group 2 3 4 5 6

Behavioral Health 12 9 15

Complex 16 13 6 1

MMTA - Cardiac 6 9 17 4

MMTA - Endocrine 4 14 13 5

MMTA - GI/GU 9 12 13 2

MMTA - Infectious 10 21 5

MMTA - Other 5 11 10 10

MMTA - Respiratory 9 8 16 3

MMTA - Surgical Aftercare 9 10 12 5

MS Rehab 7 3 8 12 6

Neuro 6 5 9 12 4

Wound 1 13 13 9

Grand Total 94 128 137 63 10

• 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

• 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

PDGM Details

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

• Estimated 71% of CY2017 episodes did not contain NRS

• Additional Clinical Groupings to account for high NRS use– Wound – 10% of total estimated periods – Complex Nursing – 4% of total estimated periods

• Approximately 30% of periods with NRS use• 47% of NRS charges

Supplies

PDGM Details

• 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%

PDGM Details

Preparing for PDGM

Preparing for PDGM

• Determine estimated revenue impact– Agency-level detail available on CMS website under “Home Health

Agency (HHA) Center” provider section

• Evaluate current processes and workflows– Are these sustainable under PDGM?

• Evaluate current agency data for key PDGM indicators

• Contact your Senators and Representatives to support the introduction of three bills (S. 3545, S. 3458, H.R. 6932) to eliminate the behavior adjustment

National Impact

National Impact

Facility Type PctFacility Based +3.0%Freestanding -0.3%

Ownership PctFor-Profit -0.8%

Gov’t Owned +2.3%Non-Profit +2.1%

Nursing/Therapy Ratio Pct1st Quartile (Lowest Nursing) -9.6%

2nd Quartile -1.0%3rd Quartile +6.2%

4th Quartile (Highest Nursing) +17.3%

Location PctRural +3.8%Urban -0.6%

• Education to all staff is essential• Strong interdepartmental communication• Reporting on key indicators driving reimbursement under

PDGM

Departments Impacted

• Understand the impact of your primary referral source• Obtain as much diagnosis information as possible at time of

referral• Strong communication with Scheduling Department

• Appropriate visit frequency at start of care• LUPA management under new structure• Timely completion of OASIS/visit documentation

Departments Impacted

• Accurate and complete coding is essential• Will determine Clinical Group 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 cognizant of diagnoses that fall under the Questionable Encounter classification

• Volume of claims requiring billing/collections efforts doubles• For the first 30-day period in an episode, shorter timeframe

to resolve all pre-billing issues prior to final claim being available to submit

• Monitor claims to ensure no processing errors once new structure is implemented

Departments Impacted

• Shorter billing period makes quick turnaround on signed orders even more important

• Need to evaluate how quickly agency is currently getting new orders to physicians

• Determine if current frequency/method of follow-up with physicians is efficient

• General– Productivity for all departments– Staffing levels required to implement optimal workflows under PDGM

• Coding– What percentage of periods would fall under a QE status?– What percentage of periods would qualify for a comorbidity adjustment?

• Orders Tracking– Average days after start of episode that 485 is sent to physician– Volume of verbal orders generated after start of episode– Average turnaround time for receipt of signed physician orders

• Billing– Days to RAP/final claim– Frequency of billing– Claim volume on outstanding accounts receivable– Volume of unbilled claims

Preparing for PDGM

• Technology can automate many of the processes needed to make PDGM a success.

• Review your technology partner’s PDGM plan and offerings– 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?

• Engage with your technology partners regularly– Participate in design sessions– Attend user feedback sessions– Share product ideas and enhancements

Preparing for PDGM

PATIENT

● Support timely and expedited billing with clear documentation and processes

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

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

● Improved communication and collaboration between cross-functional teams

● Accurate and 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

● Streamline and simplify the receipt of compliant physician signed & dated certifications, orders, & FTF documentation confirmed

● Obtain signatures electronically

● Simplify care coordination with remote care teams

Brian HarrisConsulting Director

BrianHarris@BlackTreeHealthcare.com(610) 536-6005 ext. 732

Consulting Outsourcing Education

Craig Mandeville,CEO at Forcura

Brian Harris,Consulting Director

Craig MandevilleCEO at Forcura

Cmandeville@Forcura.com800.378.0596