Last June 28, the Centers for Medicare & Medicaid Services (CMS) issued the Home Health Prospective Payment System (HH PPS) proposed rule for 2022, which re-focuses the shift from paying for home health services based on volume to a system that incentivizes higher quality care. 

One of the most significant and noteworthy changes is the nationwide expansion of the home health value-based purchasing (HHVBP) model. Other changes are related to the Patient-Driven Groupings Model (PDGM), Low-Utilization Payment Adjustments (LUPAs), Conditions of Participation (CoPs), Quality Reporting Program, and COVID-19 blanket waivers.

Here are the key takeaways from the proposed rule in summary:

Increase in Medicare Payments for Home Health

CMS proposed to increase Medicare payments to home health agencies by 1.7% next year, which equates to an estimated $310 million growth.

HHVBP National Expansion

CMS is proposing to expand HHVBP nationwide beginning January 1, 2022 from the nine (9) current participating states (i.e. Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee).

There was also a proposal to end the original HHVBP Model one year early for the agencies in the current participating states. This means that CMS would not use CY 2020 data to make payment adjustments for next year. Furthermore, if realized in the final rule, the first performance year of the expanded HHVBP Model would be CY 2022, using quality performance data from that year to calculate payment adjustments under the expanded model in CY 2024.

PDGM Developments

CMS stated that it will not be making any changes to the 4.36% behavioral adjustment in PDGM and that it plans on delaying any corrections until the COVID-19 Public Health Emergency (PHE) is over and more reliable data is available..

On the other hand, the proposed rule mentioned that CMS is conducting ‘preliminary analyses’ of the data from the first year of PDGM, specifically data pertaining to admission source, timing, clinical grouping, functional-impairment level, and more. Insights into how differences between assumed and actual behavior changes are being analyzed were also discussed.

New OT Flexibility and corresponding LUPA adjustment

CMS will implement regulatory modifications to allow an Occupational Therapist (OT) to complete the initial assessment and SOC comprehensive assessment for Medicare patients when OT is ordered with speech-language pathology (SLP) and/or physical therapy (PT) but where skilled nursing is not initially part of the plan of care.

This will not change nor pose a conflict to the statutory requirements for establishing Medicare program eligibility. Only the need for skilled nursing, PT and/or SLP services continue to establish eligibility for Medicare home health benefit.

Consequently, when OTs are able to conduct assessments and certify for home health services, CMS is also proposing an add-on factor to adjust for that first skilled OT visit in LUPA periods.

Quality Reporting Program

CMS is also proposing some modifications to the Home Health Quality Reporting Program such as the removal of certain measures that increase the burden on providers and adjustments for home infusion therapy. Specifically, they will be removing the OASIS-based “Drug Education of All Medications Provided to Patient/Caregiver During All Episodes of Care” measure because its performance is high enough among home health care agencies that meaningful distinctions between performances can no longer be made.

Conditions of Participation (CoP)

CMS is proposing to make permanent selected regulatory blanket waivers related to home health aide supervision and the use of telecommunication that were issued during the COVID-19 public health emergency (PHE). CMS believes that allowing telecommunication flexibility for the required 14-day on-site supervisory visit by home health aides is an important component in assessing the quality of care and services and to ensure that they meet the patient’s needs.

Keeping the Stability in Spite of the Changes

Aside from additional flexibilities and incentives, other changes in the CMS proposed rule were more measured and subtle, most likely to allow agencies to recuperate from challenges related to the COVID-19 PHE.

On the other hand, the changes in the proposed rule will most probably disrupt established workflows so agencies can integrate the new flexibilities and comply with new standards, or at least to pursue incentives. To stay on top of all changes, it would help to work with a team who is knowledgeable of the technicalities of compliance standards. The right partner leverages data and employs the right tools to help you establish benchmarks that provide a bird’s eye view of your processes, so you can get back to the rhythm and keep consistent streamlined workflows. Simply put, find a partner that can help provide stability in the midst of the ever-changing home health landscape.

The post Key Takeaways: 2022 Proposed Payment Rule; HHVBP National Expansion first appeared on Qavalo.

When OASIS submission, coding, and QA review were streamlined, Qavalo’s client agencies saw significant improvements in their OASIS turnaround time and realized better compliance and profitability.

With the right outsourcing partner, Qavalo clients have been able to get the support their in-house teams need to find efficiencies in their documentation workflow and seize big picture process improvement opportunities.

Benefits Realized

• Consistent OASIS submission-to-completion process
• Faster OASIS submission time
• Shorter OASIS turnaround time
• Declining LUPA rates
• Optimized reimbursement values

PDGM Turnaround Time Challenges

The Patient-Driven Groupings Model (PDGM) overhauled the entire home health reimbursement system with new case-mix weight calculations, new LUPA thresholds, new Request for Anticipated Payment (RAP) requirements, and shorter payment periods, among other big changes.

Request for Anticipated Payment (RAP)
In 2020, CMS introduced RAP, requiring agencies to submit initial documentation to authorize care under a home health agency and establish the care episode. Though a complete OASIS is no longer a requirement to file a No-Pay RAP this year, it is still best for agencies to complete the OASIS within the 5-day window period.

HHRG and HIPPS codes
Based on an OASIS assessment, 30-day periods under PDGM are classified under a variety of patient information and other clinical characteristics, such as admission source, timing, clinical grouping, functional impairment, and comorbidity. This results in a Home Health Resource Group (HHRG) combination for which CMS will generate a PDGM case-mix weight represented as a Health Insurance Prospective Payment System (HIPPS) code on Medicare claims.

Completion of the OASIS in time for RAP filing allows agencies to determine the claim’s HHRG classification and a HIPPS code that is more reflective of the actual patient case. This is important so that the assigned HIPPS code in the RAP would be more consistent with the HIPPS code in the final claim, thus lowering the chance of the agency being flagged for an Additional Development Request (ADR).

Low Utilization Payment Adjustments (LUPA)
With PDGM, LUPA thresholds vary per HHRG over a 30-day period, which means agencies should closely monitor different LUPA thresholds and visit intensities for each patient. Early identification of the LUPA threshold though the HHRG and HIPPS code will help agencies plot and schedule visits accordingly to prevent claims falling under LUPA.

These changes underscore the need for home health agencies to fast-track their process, improve documentation turnaround, and observe strict OASIS completion timelines in order to address key functions that affect claims approvals and reimbursement values. This is no easy task since an OASIS needs to undergo a number of processes, including coding and QA review, before being completed. In many cases, this can take up to 10 days—or ⅓ of the care period—if processes are not streamlined.

Qavalo Solutions in Numbers

To address the abovementioned challenges, Qavalo applies several workarounds and best practices to help agencies achieve the ideal workflow and succeed in timely submissions. 

• Timely coding and OASIS review to allow agencies to identify LUPA thresholds ahead of time, and generate a HIPPS code that is reflective of the actual patient case.
• Coding is done as soon as the OASIS is available in the QA manager.
• Coders are available seven (7) days a week.
• OASIS QA review is completed within 48 hours after coding.
• There is efficient resolution of escalations of OASIS quality issues.
• Qavalo proactively notifies agencies of trends on late submissions of OASIS by the clinicians.

Figure 1.1 shows the average OASIS submission time of clinicians across all home health agency clients of Qavalo. In January 2021, average OASIS submission was at 2.52 days, and by May 2021, this decreased to only 1.41 days.

More importantly, figure 1.2 below shows the average OASIS turnaround time from clinician submission to final approval. From January to May of 2021, Qavalo home health agency clients were able to realize completion of the OASIS within an average of 3.16 days.

Though a complete OASIS is not required to submit No-Pay RAPs since January 2021, clinicians were able to maintain early submission of OASIS, allowing other OASIS processes,  such as coding and QA review, to be accomplished in a timely manner. In addition, Qavalo’s QA review program supports clinician reeducation, helping them improve their charting skills overtime. This resulted in an efficient end-to-end average OASIS turnaround time of 3.16 days, which falls within the 5-day RAP filing window.

Due to efficiencies in the OASIS completion timeline, LUPA thresholds were identified early on in the payment period, allowing agencies to properly plot visit schedules, and anticipate and address missed or cancelled visits, thus avoiding LUPAs.

Figure 2 below shows sample data from one of Qavalo’s clients, Palmeria Home Health in Arizona and Nevada. The graph shows the percentage of Palmeira’s LUPA episodes from the fourth quarter of 2020 to the second quarter of 2021.

In Q4 of 2020, only 7% of all episodes fell under LUPA. Even with the implementation of No-Pay RAPs in 2021, when the OASIS is no longer required to be completed within 5 days, LUPA rates continued to drop at 6% by Q1 and down to only 4% by Q2.

While early identification of LUPA thresholds greatly helped agencies, LUPAs were not completely avoided because of some uncontrollable factors such as cancelled visits due to patients’ anxiety towards COVID-19.

The Right Partner for the Job 

Based on data, Qavalo’s home health agency clients realized a better OASIS turnaround time. Beyond the scope of documentation review and coding, Qavalo maintains ongoing collaboration with in-house teams and leverages data to help agencies have a comprehensive view of their documentation workflow and properly address gaps. This path of progress will only lead to more streamlined processes, resulting in better patient outcomes and business profitability.

The post PDGM Challenges: Optimizing Profitability Through Efficient OASIS Turnaround first appeared on Qavalo.

The Centers for Medicare & Medicaid Services (CMS) addressed concerns regarding GG codes in the recently released Outcome Assessment Information Set (OASIS) Q&As for quarter 1 of 2021.

Clinicians still find it challenging to correctly assess and code the functional M items and the GG items since the revision of OASIS from version C to D in 2019. Previously used for patient assessments in skilled nursing and in-patient rehabilitation facilities, GG items did not always transition easily to home health. The confusion lies in how clinicians are inclined to follow long-standing OASIS advice to avoid contradictory answers on the functional M items. They are often confused about what is and is not supposed to be considered when assessing the patient for GG items because they are so familiar with M item assessments.

There may be specific tasks that are common to GG items and functional M items, but it does not mean that they should exactly match. However, using a 6-point scale, the GG scoring for the patient’s performance on a task during the Start of Care (SOC) and the Resumption of Care (ROC) can really help the clinicians to also score the functional M items correctly.

The Difference

What’s the difference between M items and GG items? M items cover a broader spectrum and must be carefully filtered through aspects of patient safety, environmental factors, and other circumstances, and be based on all available information, including evaluations and assessments. The GG items require a more narrow evaluation of only the specific task being assessed.

One major difference between M items and GG items is how the “majority of tasks” convention is applied. This convention applies when a patient’s ability to perform a task varies. Guidance from CMS tells clinicians to follow the “majority of tasks” convention when assessing M items but not when assessing GG items.

The GG items focus on the functional abilities and goals assessed by the clinician during SOC and ROC. Using the 6-point scaling system, the points reflect the patient’s SOC/ROC baseline functional status as observed by the clinicians during the patient’s activities. Similar to functional M items, the GG sections also take into account factors that impact the patient’s functional ability, such as the environment or situations encountered in the home. In addition, this section requires the clinician to identify the patient’s goal upon discharge.

On the other hand, the intent of functional M items (M1800s) is to identify the patient’s ability to safely perform instrumental activities of daily living (IADLs) associated with a specific task, but not necessarily the actual performance. Timelines and activities considered for GG items are often different from similar M items for IADLs.

One thing to note with GG items is that they are very specific on the activities the patient needs to perform, including the required assistance. Meanwhile, the M1800s responses describe the patient’s ability to perform more than 50% of activities under one task at a given time period under consideration.

The Solution

The differences between GG and functional M items mean that clinicians should consider each item individually and code it according to the guidelines specific to that item. Being diligent in staying up to date with the OASIS guidance released by CMS through quarterly Q&As is the key.

The section GG has no right or wrong answer as long as it is a true reflection of the patient’s performance of the task. It is a process that requires careful assessment and evaluation from the clinicians. Keenly observing the patient’s performance of each task can greatly help in correctly coding the GG and functional M items.

New clinicians who just entered the home health industry may find documenting the OASIS assessment quite confusing. It will be helpful for home health agencies to partner with outsourcing providers who are knowledgeable of the OASIS Guidance Manual and know the application of the OASIS item conventions. They can help corroborate the clinicians’ assessment findings with other supporting medical documentation to make the OASIS assessment more cohesive, especially on the M items and section GG.

Mastery of OASIS documentation takes time. One must understand the intent of each section, including the M items. Without adequate knowledge and support, this could compromise the quality of care, reimbursement value, and most importantly, patient outcomes.

The post OASIS Q1 Update: Decoding GG Codes first appeared on Qavalo.

The New CMS ADT Mandate

There is a new mandate from the Centers for Medicare and Medicaid Services (CMS) on sharing admissions, discharge, and transfer (ADT) data among care providers, with the aim of improving care coordination and lowering readmissions.

As of May 1, the new regulation will require hospitals to notify all applicable post-acute care service providers and suppliers when patients are admitted to or discharged from the hospital, or transferred to another facility. Hospitals must share ADT information with primary care physicians (PCPs), physician groups, skilled nursing facilities (SNFs), home health, hospice agencies, and other providers in their care community.

This new CMS mandate promotes the significant role of interoperability in the healthcare industry. According to the Healthcare Information and Management Systems Society (HIMMS), interoperability is the ability of different information systems, devices, or applications to connect, in a coordinated manner, within and across organizational boundaries to access, exchange, and cooperatively use data amongst stakeholders, with the goal of optimizing the health of individuals and populations. Interoperability furthers the goals of optimizing healthcare by providing access to the right information needed to understand and address the health of individuals and populations.

Interoperability in Home Care

Value of Interoperability

One of the major takeaways from the 2021 Home Health Care News Outlook Survey and Report was about the potential of interoperability to encourage growth in home care. It showed that most respondents agreed that interoperability will have a high impact on their organization’s yearly growth.

Significantly, a recent survey about interoperability in post-acute care indicated that 74% of physician groups and other referral sources would send more referrals to post-acute care providers, including home-based care agencies, that offer greater electronic data access.

The results also showed that 95% of home-based care respondents and 71% of skilled nursing respondents acknowledged the importance of interoperability to their referral sources. These findings further underscore the growing value of interoperability.

Another contributing factor to the importance of interoperability is the need to process key patient information faster. This is due to increasing industry standards like shorter Request for Anticipated Payment (RAP) filing timelines and Patient-Driven Groupings Model’s (PDGM) compressed revenue cycle.

Minding the Gap

Despite this, many providers still only meet “basic maturity” interoperability standards. This refers to “the ability to receive patient demographic data and clinical information, such as diagnosis codes and allergies, electronically.” In order to reach high-performing mature interoperability, providers need to be able to receive physician orders, patient forms and visit notes, medication information, and patient status updates.

As referral sources grow more demanding, providers that don’t prioritize meeting these standards could be left behind and lose business. This is an opportunity for home-based care providers to strategically address their interoperability shortcomings as soon as possible to stay competitive.

Preparing your agency for interoperability

To effectively position your organization as the partner of choice, you must first evaluate your agency’s interoperability capabilities and then identify key areas of improvement.

Have a conversation with your EMR provider to make sure their capabilities match the expectations of your referral partners. Interoperability goes beyond documentation, so it is essential to work with an EMR that already has the framework to allow businesses to collaborate with a wider healthcare network. The same collaborative approach should also be applied with your third-party contractors and outsourcing partners.

Choose an outsourcing provider that can support your interoperability goals. The right outsourcing partner has the vision to leverage technology and data-driven processes, which can lay the groundwork for interoperability. This is an essential part of embracing patient-centric solutions, which will have a positive impact on all fronts. It will improve referral relationships, increase your organization’s credibility within the home healthcare network, and empower clinicians with key information useful for delivering higher quality patient care.

Resources:
CMS Interoperability and Patient Access Final Rule >
HHCN: 74% of Referral Sources Prefer Home-Based Care Providers That Meet Interoperability Standards >

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