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 [email protected]
(610) 536-6005 ext. 712
Annie ErstlingChief Strategy Officer
[email protected](904) 707-2902