{"id":545,"date":"2018-11-13T07:00:46","date_gmt":"2018-11-13T07:00:46","guid":{"rendered":"https:\/\/advantagehcconsulting.com\/blog\/?p=545"},"modified":"2018-11-12T15:50:39","modified_gmt":"2018-11-12T15:50:39","slug":"reimbursement-cms-hangs-onto-behavioral-assumption-adjustment-cuts-despite-industry-outcry","status":"publish","type":"post","link":"https:\/\/advantagehcconsulting.com\/blog\/2018\/11\/13\/reimbursement-cms-hangs-onto-behavioral-assumption-adjustment-cuts-despite-industry-outcry\/","title":{"rendered":"Reimbursement: CMS Hangs Onto Behavioral Assumption Adjustment Cuts, Despite Industry Outcry"},"content":{"rendered":"\n<figure class=\"wp-block-image is-resized\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/advantagehcconsulting.com\/blog\/wp-content\/uploads\/2018\/11\/PDPM-_-Patient-Driven-Grouping-Model.png\" alt=\"\" class=\"wp-image-546\" width=\"580\" height=\"306\" srcset=\"https:\/\/advantagehcconsulting.com\/blog\/wp-content\/uploads\/2018\/11\/PDPM-_-Patient-Driven-Grouping-Model.png 491w, https:\/\/advantagehcconsulting.com\/blog\/wp-content\/uploads\/2018\/11\/PDPM-_-Patient-Driven-Grouping-Model-300x158.png 300w, https:\/\/advantagehcconsulting.com\/blog\/wp-content\/uploads\/2018\/11\/PDPM-_-Patient-Driven-Grouping-Model-210x111.png 210w\" sizes=\"auto, (max-width: 580px) 100vw, 580px\" \/><\/figure>\n\n\n\n<p><strong><em>I<\/em><\/strong><em><strong>ndustry<\/strong><\/em><strong><em>\u00a0needs Congress\u2019 help.<\/em><\/strong><\/p>\n\n\n\n<p>While the Patient-Driven Groupings Model is supposed to be a budget-neutral reform to how Medicare pays home health agencies, in&nbsp;realityproviders will see a big cut in transitioning to the new payment system, the 2019 Home Health Prospective Payment System final rule indicates.<\/p>\n\n\n\n<p>When the\u00a0<strong>Centers for Medicare &amp; Medicaid Services\u00a0<\/strong>proposed PDGM back in July, many providers were surprised to see a rate reduction incorporated into the change. CMS\u2019s assertion that it would assume agencies would engage in clinical group upcoding, comorbidity diagnosis code upcoding, and Low Utilization Payment Adjustment gaming was \u201cshocking\u201d and \u201coffensive,\u201d attorney\u00a0<strong>Robert Markette Jr.\u00a0<\/strong>with\u00a0<strong>Hall Render\u00a0<\/strong>in Indianapolis said at the time.<\/p>\n\n\n\n<figure class=\"wp-block-image\"><img decoding=\"async\" src=\"https:\/\/www.supercoder.com\/webroot\/upload\/articles_pdf\/2018\/hcw\/HCW_v27_p312.gif\" alt=\"\"\/><\/figure>\n\n\n\n<p>Many of the more than 1,300 commenters on the proposed rule took CMS to task for making the preemptive adjustments, which it estimated would be 6.42 percent.<\/p>\n\n\n\n<p>CMS summarizes many of the comments in the final rule it issued Oct. 31. For example, commenters said the assumptions:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>\u201cappear to be randomly determined, inappropriate and that there is no evidence to support them\u201d<\/li><li>\u201clack any foundation in actual&nbsp;evidence based&nbsp;data and therefore penalize providers in an arbitrary and capricious fashion\u201d<\/li><li>\u201care \u2018mere guesses\u2019 and appear to be used solely to reduce home health payments\u201d<\/li><li>\u201cappear to be overly complex and unsubstantiated\u201d and<\/li><li>\u201care illogical because the broad assumptions \u2026&nbsp;basically&nbsp;construct a completely new payment system that is predicated on a presumption that HHAs will attempt to manipulate the system.\u201d CMS dismisses those concerns, repeatedly noting that the Bipartisan Budget Act of 2018, which required budget neutrality for PDGM, demands the agency make behavioral assumptions.<\/li><\/ul>\n\n\n\n<p><strong>Alternate viewpoint:&nbsp;<\/strong>The&nbsp;<strong>National Association for Home Care &amp; Hospice&nbsp;<\/strong>disagrees with CMS on this point. \u201cWe think there is more flexibility than CMS is reading into the provision,\u201d NAHC President&nbsp;<strong>William Dombi&nbsp;<\/strong>tells&nbsp;<strong>Eli<\/strong>.<\/p>\n\n\n\n<p>Nevertheless, CMS finalizes that interpretation \u2014 apparently backed by its legal counsel, Dombi adds \u2014 and the behavioral adjustments in the final rule scheduled for publication in the Nov. 13&nbsp;<em>Federal Register<\/em>. CMS doesn\u2019t set a specific adjustment level yet, citing the need for updated data, but the last estimate was a 6.42 percent cut.<\/p>\n\n\n\n<p>Even if BBA \u201918 didn\u2019t require the preemptive assumption cuts, CMS lays out a multitude of reasons why the reductions are reasonable and necessary, including:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Past experience.&nbsp;<\/strong>Over the course of HH PPS, CMS has repeatedly found evidence of significant case-mix growth not due to real changes in patients\u2019 conditions. For example, \u201cbetween CY 2000 and 2010, total case-mix change was 23.90 percent, with 20.08 considered nominal case-mix growth,\u201d CMS says.<\/li><li><strong>Other settings.&nbsp;<\/strong>Commenters pointed out that CMS isn\u2019t using preemptive adjustments for Skilled Nursing Facilities in its transition to a revamped case-mix system in 2019. CMS responds that the SNF payment system adjustments aren\u2019t required by law. And in the hospital setting, CMS did use similar adjustments when it transitioned from DRGs to MS\u2013DRGs.<\/li><li><strong>Current practices.&nbsp;<\/strong>\u201cIn the current HH PPS, the assignment of points as part of the clinical level in the case-mix methodology is dependent upon the reporting of diagnoses,\u201d CMS notes. \u201cHowever, the points assigned are not generally dependent on whether the diagnosis is reported as the primary diagnosis or other diagnosis, except for a few exceptions. This means, that for most of the clinical point assignments, the ordering of the diagnosis does not matter as much as whether the diagnosis is present or not.\u201d With the ordering of the codes making an impact under PDGM, you would naturally expect behavioral changes that are not gaming or upcoding, CMS says.<\/li><li><strong>OASIS limits.&nbsp;<\/strong>Likewise, OASIS has only six slots to record comorbidity codes, while home health claims have 24 slots for secondary codes. One would naturally expect to see more codes that qualify patients for comorbidity adjustments under PDGM, compared to the current information.<\/li><li><strong>LUPA patterns.&nbsp;<\/strong>When HH PPS began, \u201cthe episode file showed that approximately 16 percent of episodes would have received a LUPA,\u201d CMS notes in the final rule. But \u201ccurrently, only about 7 percent of all 60-day episodes receive a LUPA. In other words, it appears HHAs changed practice patterns such that more than half of 60-day episodes that would have been LUPAs upon implementation of the HH PPS are now&nbsp;non-LUPAs.\u201d CMS expects the same pattern to occur with PDGM. \u201cCurrent data for CY 2017 suggest that what would be about one-third of the LUPA episodes with visits near the LUPA threshold would move up to become non-LUPA episodes as we currently see clustering of episodes at and around the current LUPA threshold of 5 visits.\u201d<\/li><li><strong>Gaming inevitability.&nbsp;<\/strong>CMS also dismisses commenter concerns that \u201cit would be difficult to change their behavior in response to the PDGM. For example, these commenters referenced the LUPA thresholds that vary by case-mix group and stated that these are difficult to understand and that it would be extremely difficult for a&nbsp;front line&nbsp;care provider to know for a specific patient whether they were close to a LUPA threshold.\u201d CMS responds that \u201cthe evidence supports a pattern of \u2018practicing to the payment\u2019. Specifically, there is ample evidence that there are notable behavior changes as they relate to payment thresholds.\u201d<\/li><\/ul>\n\n\n\n<p>The data and facts are driving this provision, CMS insists. \u201cWe did not intend to imply that HHAs would engage in unethical behavior; therefore, these assumptions are not meant to be punitive,\u201d CMS says in the final rule.<\/p>\n\n\n\n<p><strong>Bottom line:&nbsp;<\/strong>\u201cWe have provided sufficient detail for these behavioral assumptions as well as referenced past rules in which nominal case-mix change has been evaluated,\u201d CMS maintains in the final rule. \u201cThe reconciliation process involving temporary and permanent adjustments required by law\u201d \u2014 which requires CMS to see whether the assumptions occurred as estimated and adjust the next year\u2019s rates \u2014 \u201cshould assure HHAs that any over or underestimate of the payment amount will be adjusted accordingly.\u201d<\/p>\n\n\n\n<p><strong>Industry Revs Up For Prospective Adjustment Fight<\/strong><\/p>\n\n\n\n<p>HHAs aren\u2019t ready to just accept the steep cut yet. \u201cWhile the new model does include some good system refinements, its foundation is severely weakened by an unwarranted and unsupported rate reduction based on nothing but pure assumptions that home health agencies will abuse the payment process,\u201d Dombi says in a release about the rule.<\/p>\n\n\n\n<p>\u201cActual changes should be the yardstick\u201d by which behavioral adjustments are made, Dombi insists in a video about the rule posted to the trade group\u2019s website.<\/p>\n\n\n\n<p><strong>Next step:&nbsp;<\/strong>Now is the time that Congress has to step in and help, Dombi says in the video. \u201cThere&nbsp;is bipartisan, bicameral legislation already pending before Congress that will permit Medicare to adjust rates only after there are actual changes in provider behaviors, not simply based on conjecture,\u201d the release adds.<\/p>\n\n\n\n<p>There is a \u201creal chance\u201d of securing legislative relief from the preemptive adjustment before the end of the year, Dombi believes. If that doesn\u2019t pan out, HHAs will have all of next year to work on it before PDGM takes effect in January 2020.<\/p>\n\n\n\n<p><strong>Do this:\u00a0<\/strong>HHAs and all of their staff should be contacting their entire congressional delegations about this matter, Dombi urges.<\/p>\n\n\n\n<p><strong><a href=\"https:\/\/www.supercoder.com\/coding-newsletters\/my-homecare-week-alert\/medical-review-heres-how-rac-reimbursement-works-and-affects-you-156735-article\"><em>Source- SuperCoder<\/em><\/a><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Industry\u00a0needs Congress\u2019 help. While the Patient-Driven Groupings Model is supposed to be a budget-neutral reform to how Medicare pays home health agencies, in&nbsp;realityproviders will see a big cut in transitioning &hellip; <a class=\"readmore\" href=\"https:\/\/advantagehcconsulting.com\/blog\/2018\/11\/13\/reimbursement-cms-hangs-onto-behavioral-assumption-adjustment-cuts-despite-industry-outcry\/\">Continue Reading &rarr;<\/a><\/p>\n","protected":false},"author":1,"featured_media":546,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[15,5],"tags":[11],"class_list":["post-545","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-home-health","category-reimbursement","tag-home-care"],"_links":{"self":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/545","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/comments?post=545"}],"version-history":[{"count":1,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/545\/revisions"}],"predecessor-version":[{"id":547,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/posts\/545\/revisions\/547"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media\/546"}],"wp:attachment":[{"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/media?parent=545"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/categories?post=545"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/advantagehcconsulting.com\/blog\/wp-json\/wp\/v2\/tags?post=545"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}