Patient Driven Groupings Model (PDGM) Readiness Series: Back Office Preparations

PDGM BACKGROUND

The Patient-Driven Groupings Model (PDGM), is the most significant change to the home health payment reform in the past 20 years. PDGM completely alters the methodology for calculating payments. An example of this is the removal of therapy utilization as a major component of payment and the reduction of payment periods from 60 to 30 days. In addition to the many clinical and overall operational modifications that will be required, these noteworthy changes in computing Medicare payment rates could also profoundly impact a provider’s PDGM reimbursement levels in comparison to historical PPS payment levels.

TRIPLE AIM GOALS

Moreover, as the CMS Rule’s label describes, all clinical processes (and related operational sub-processes) will require improvement initiatives that focus on achieving CMS’s Triple Aim Goals – achieving patient satisfaction, quality patient outcomes and cost-effective healthcare delivery. So, what does a provider need to do between now and the actual implementation of PDGM in 2020?

PDGM TRANSITION PLAN

Providers should immediately develop a transitional PDGM implementation plan for the organization to achieve effective and complete operational readiness. Each transition plan needs to move away from the historical PPS protocols, identify the far reaching clinical, operational, and financial requirements under the PDGM Rule, and set specific processes and policies in place that are in alignment with the new requirements.

PDGM READINESS SERIES INTRO

In summary, home health providers need to be proactive in identifying how the PDGM Rule will directly impact them financially, clinically and operationally. This three-part series will discuss important areas of focus for agencies to consider to ensure PDGM readiness. This series will provide the framework for agencies to develop and implement strategies that achieve operational readiness before the transition to the PDGM Model in January 2020.

BACK-OFFICE PREPARATION CHECKLIST

Below are the back-office items providers need to consider to understand the impact of PDGM and what changes need to be made to better align with the new payment model.

EMR VENDORS

Review EMR for complete PDGM readiness
Identify whether EMR vendor has proven their complete PDGM readiness through test environment results utilizing the current EMR database

REFERRAL SOURCES

% Community vs. institutional
Conversion rate

QUALITY

Patient appropriate for home health
Adequate information for coding
Adequate Face to Face (F2F) supporting documentation

REFERRAL PROCESSING

Review current process for efficiency
Identify whether there are delays in Start of Care (SOC) related to inefficient referral processing

BILLING STAFF

Timely insurance verification
Adequate staffing to support doubling of billing periods

PHYSICIAN ORDERS

Review current process:
- Current number of days to final bill
- Process includes specific guidelines to ensure timely orders

STAFFING

Adequate staffing to support timely processing and follow up on outstanding orders
Timely F2F Encounters

DAYS TO RAP

Compare the providers’ days to RAP metric to industry best practice
OASIS & coding process-cycle time conducive to shorter 30-day billing cycle
Current OASIS, coding & billing leadership confidence in maintaining or improving agency’s best-practice position within the PDGM environment
Adequate staffing to support increase to 30-day billing periods and potential increase in SOC
Knowledgeable in acceptable primary diagnosis under PDGM