PDGM: Tackling Referral and Intake Complexities with Change Management

For home health organizations, referral and intake directly impact an agencies core operations and ability to provide appropriate care and bill in a timely manner. PDGM adds a new layer of complexity to this process by introducing the 30-day billing periods and admission source. Understanding these key components and assessing current referral and intake practices is pertinent when preparing for take-off under PDGM.

PDGM introduces 30-day billing periods within a 60-day episode as well as new determinants for defining the admission source and timing. However, it is important to note that the requirements for clinical documentation will still occur on the 60-day episode basis.

Under PDGM there will be two period timing categories, early and late. Only the initial 30-day period will be considered early in this new reimbursement model. All subsequent 30-day episodes, including recertifications, will be considered late unless there is a break in home health care for longer than 60 days. In this case, the new admission 30-day start of care period will be early.

When determining the Home Health Resource Group (HHRG), organizations must also consider the admission source. Generally, the initial start of care period, or the first 30-day period in a sequence, will only be considered institutional when the patient is discharged from an institutional setting in the 14 days prior to the start of home health services. Community admissions are those in which the patient did not receive acute or post acute care within 14 days prior to the start of home health services. All subsequent 30-day periods are considered community. Figure 1 displays a recast of 2017 Medicare claims data to show at a national level the distribution of admission source and timing under the two 30-day payment periods.

From a reimbursement standpoint, institutional and early periods tend to use more of resources and visits than community patients, therefore these periods are reimbursed at a higher level.  This may reduce payments by as much as 35% from the first 30-day period (early, institutional) to the second 30-day period (late, community). Figure 2 shows national reimbursement averages for each source and timing type.

Referral and Intake Functions Operational Change Management

As home health organizations further their understanding of admission source and timing, they must focus on referral relationships as they are key to the intake process. An assessment of the intake process is critical to identifying potentials gaps or challenges and proactively addressing them. Organizations must ensure that all intake staff are well educated on the components of PDGM related to the intake process including how admission sources, period timing, and documentation requirements affect reimbursement.

Create: Develop an in-depth checklist for staff that covers all aspects of the intake process that affect reimbursement, particularly admission sources, period timing, and documentation requirements.

Developing a comprehensive intake checklist will help to verify receipt of the following information from referrals:

• Primary diagnosis and comorbidity diagnoses codes
• Physician face-to-face encounter notes
• Home health services requested
• Facility/MD documents to support the need for home health services ordered
• A contact number to verify source information
• Admission Source and 14-day lookback prior to admission
• Determine accurate episode timing

In addition to assessing intake processes and educating intake staff, it is imperative to identify which referrals provide complete information and which require extra attention from your staff to gather all the necessary documentation.  Understand why different referrals are problematic and identify the gaps in process. A review of your current staffing structure and processes may be necessary to better understand obstacles related to time-consuming tasks or manual processes.  Gathering data on your referral sources may require the introduction of electronic referral tools, education, or the creation of updated processes.

Evaluate: Analyze your current referrals to identify areas of concern. Identify which sources provide complete information and which require extra attention from your staff to gather all the necessary documentation.

It is imperative to consider what information must be gathered upon referral to prevent downstream issues. An organizations ability to maximize revenue is contingent upon accurate intake information.

Key take-aways:

• Has your organization conducted an assessment of your referral sources (institutional vs. community) and episode timing under PDGM?
• Are your referral sources sending over detailed and complete documentation?
• Has your organization evaluated the processes and staffing levels in the intake department?
• Does your EMR provide KPIs or Reports that let you know where your referrals are coming from and the percentage of them that are Community vs. Institutional?
• Do you have an integrated Electronic Visit Verification process embedded in your intake workflow to verify Insurance information including any current or past service benefits including home health care benefits?
• Can the information you collect at Intake flow forward to the Start of Care visit?

Want to learn more on PDGM’s impacts? Our ebook “Soaring to Success Under PDGM” gives a deep-dive into the clinical, financial, and operational impacts PDGM will have on home health providers and what they can do to prepare.