OAHC PDGM New New Normal PowerPoint...ØUpdate of payor matrix with new policies and billing codes Initial Impact of PDGM Intake 4 8/18/20 3 5 ØEarly identification of patient timing

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New, New Normal under PDGM and COVID-19

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ØInitial Impact of PDGM

ØImpact of PDGM and COVID-19

ØFuture Predictions

Overview

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Intake

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Ø New referrals lack all information required to process correctlyo Causes issues that prevent proper codingo Impact on potential reimbursement

Ø Experiencing knowledge gaps, specifically at the Intake staff levelo Need to track Clinical Groupings received

Ø Update of payor matrix with new policies and billing codes

Initial Impact of PDGM

Intake

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Ø Early identification of patient timingo Will impact HHRG scoredo LUPA thresholds

Ø Initial increase in Early and Institutional periodsØ Increased use of e-fax and technology

o Technology gaps across agencies

Initial Impact of PDGM (Continued)

Intake

Ø Source: Medicare LDS 2018 and Strategic Healthcare Programs (SHP) analysis of PDGM KPI data for 1/1/2020-3/31/2020 period as of 4/22/2020

National-Period Timing National-Admission Source

Source Early Late Community Institutional

2018 Medicare LDS 32.0% 68.0% 74.7% 25.3%

PDGM Through 3/31/20 48.6% 51.4% 63.8% 36.2%

% Difference 16.6% -16.6% -10.9% 10.9%

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Intake

Impact of PDGM and COVID-19

Ø Impact on referral sourceso Decrease in number of referrals received

Ø Update current technology to accommodate remote workforceo Portal access for increased productivity

Source Timing January February March April May YTD 2020Community Early 22.5% 12.7% 10.2% 9.3% 15.5% 13.6%Community Late 29.7% 55.2% 59.0% 67.6% 53.4% 54.1%Community Total 52.2% 67.9% 69.2% 76.8% 68.9% 67.7%Institutional Early 45.0% 28.1% 25.1% 17.2% 26.1% 27.5%Institutional Late 2.8% 3.9% 5.7% 6.0% 5.0% 4.8%Institutional Total 47.8% 32.1% 30.8% 23.2% 31.1% 32.3%

Ø Source: Strategic Healthcare Programs (SHP)

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Intake

Future Predictions

Ø Wave of increased referrals into Home Health as Public Health Emergency (PHE) subsideso Result will be overall normalization of

patient census

Ø Continued increase in communication among clinicians and clerical staff

Ø Unknown future status of remote workforceo Further development of technology uses to

improve productivity

Ø Impact of a potential second wave?

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Case Management

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Impact of PDGM

Case Management


Ø Increased scrutiny on OASIS turnaround timesØ Clinical Groupings

o QEs accounted for 0.1% of Q1 2020 PDGM periods o Decrease in MMTA – Other periods and in an increase

in the more specific MMTA categories o Increase in MS and Neuro Rehab periods in Q1 2020

Ø Therapy still required to provide effective careo MS Rehab and Neuro Rehab accounted for 30.2% of Q1

2020 periodsØ Increased usage of telehealth to manage visits based on

patient’s condition

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Ø CMS has received an increased volume of beneficiary complaints categorized as “barriers to access of care”

Ø Exploring new staffing models Ø CMS has not set definitive expectations for providers

concerning discharges o Transfer to Inpatient Hospital o Discharge to other institutional settings (SNF, IRF, IPF,

LTCH)Ø Need for increased monitoring of missed visits

o New LUPA thresholds add complexityo Shorter period available to make up missed visits and

avoid LUPAs

Impact of PDGM (Continued)

Case Management

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Ø LUPAs

Ø Length of Stay

Ø Case Mixo PDGM Budget Neutrality Expectations: 1.000o PDGM 1/1/2020-3/31/2020: 1.111


Case Management

Source LUPA %2018 Medicare LDS 7.4%PDGM 1/1/2020-3/31/2020 9.7%Difference 2.3%

Source Length of Stay Pre-PDGM Average 46.0PDGM 1/1/2020-3/31/2020 34.5% Difference -25.0%


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Ø Census fluctuations compared to 3/1/2020

Ø Increased need for PPE and establishing proper supply protocols

Ø Telehealth utilization becomes more of a necessity than a strategic decision

Ø Increase in LUPAs due to patient refusal and clinician's availability

Ø Decrease in therapy utilizationØ Impact on OASIS completion

Impacts of PDGM and COVID-19

Case Management

3/15/2020 3/31/2020 4/15/2020 4/30/2020 5/15/2020Top 20 HH Clients +0.8% -0.9% -4.5% -5.0% -3.9%

Ø Source: BlackTree’s Top HH Clients

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Ø Agencies can perform initial assessments and determine patients’ homebound status remotely or by record review

Ø Homebound standard loosened to account for patients who are self-quarantined

Ø Effective March 1st, 2020, home health patients can be under the care of a nurse practitioner, clinical nurse specialist, or a physician assistant who is working in accordance with State lawo Oregon flexibility pending the Home Health Planning and Improvement

Act (HR 4993 / S 2814)

Ø Waived the annual onsite aide supervisory visitØ OT can perform the initial and comprehensive assessment for

all patients receiving therapy

Regulatory Changes under COVID-19

Case Management

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Ø LUPAs

Ø Length of Stay

Ø Case Mixo PDGM 1/1/2020-3/31/2020: 1.111o PDGM 1/1/2020-4/30/2020: 1.099o PDGM 4/1/2020-4/30/2020: 1.052o PDGM 4/1/2020-6/30/2020: 1.041


Case Management

Source Pds w/ LUPAs Stays w/ LUPAsPDGM 1/1/2020-3/31/2020 9.7% 11.1%PDGM 4/1/2020-4/30/2020 13.6% 21.4%Difference 3.9% 10.3%

Source Length of Stay PDGM 1/1/2020-3/31/2020 34.5PDGM 1/1/2020-4/30/2020 32.6% Difference -5.5%

Ø Source: Strategic Healthcare Programs (SHP) analysis of PDGM KPI data for the following periods 1/1/2020-3/31/2020 period as of 4/22/2020 and 1/1/2020-4/30/2020 as of 5/13/2020

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Ø Expansion of managing patient care via telehealtho Telehealth v. in person

Ø Potential increase in patient census and managing large patient volume

Ø Schedulers need to be prepared for influx of referrals to home health as impact on hospitals decreases

Ø Stabilization of LUPA% Ø Heightened focus on LUPA Management Ø Continued education required for staff on ongoing changes Ø Continued strong communication required with Intake and

clinical teams

Future Predictions

Case Management

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Coding & OASIS

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Ø Minimal Questionable Encounters (QEs) and EMR preparedness to prevent

Ø Few diagnosis changes reported mid-periodo Communication and documentation of mid-period coding changes were

not clearly defined o There is no requirement to complete another follow-up (RFA 05)

assessment, or Significant Change in Condition (SCIC), to ensure diagnosis coding on the claim matches the assessment if diagnosis codes change between periods

Ø Increase in OASIS submission errorso Providers experienced a high volume of issues with iQIESo Rejections received without rejection reasonso Medicare Advantage (MA) OASIS rejected for missing MBI number even

though plan does not require itØ Some agencies testing pre-coding at Intake

Impact of PDGM

Coding & OASIS

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Ø Clinical Groupings


Coding & OASIS

Clinical GroupingsMedicare LDS

2018PDGM

1/1/2020-3/31/2020Difference

LDS to Q1 2020MS_REHAB 17.0% 19.7% 2.7%

MMTA_CARDIAC 16.1% 17.8% 1.7%WOUND 9.5% 13.9% 4.4%

NEURO_REHAB 8.6% 10.5% 1.9%MMTA_RESP 7.8% 9.3% 1.5%

MMTA_INFECT 4.2% 5.4% 1.2%MMTA_ENDO 4.4% 5.2% 0.8%MMTA_GI_GU 4.0% 5.1% 1.1%MMTA_AFTER 3.6% 4.3% 0.7%MMTA_OTHER 7.4% 2.9% -4.5%

COMPLEX 1.9% 3.3% 1.4%BEHAVE_HEALTH 2.0% 2.7% 0.7%

QE 13.5% 0.1% -13.4%TOTAL 100% 100%


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Ø Comorbidity Adjustmentso Higher than projected comorbidity adjustments on

Q1 2020 PDGM periods

Ø Functional Impairment Levels o Variation in domains may be due to increased

collaboration among disciplines


Coding & OASIS

Source No Low High2018 Medicare LDS 56.6% 35.1% 8.2%PDGM 1/1/2020-3/31/2020 48.3% 37.9% 13.8%Difference -8.3% 2.8% 5.6%

Source Low Medium High2018 Medicare LDS 34.4% 33.3% 32.3%PDGM 1/1/2020-3/31/2020 23.5% 32.9% 43.7%Difference -10.9% -0.4% 11.4%


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Ø Introduction of new COVID related diagnosis codeso Complex Nursing and MMTA - Respiratory periods have

increased since start of PHE

Ø Extension of the 5-day OASIS completion requirement for the comprehensive assessment to 30 days

Ø Waiving of the 30-day OASIS submission requirement

Ø OASIS-E has been suspended until January 1st of the year that is at least one full calendar year after the end of the PHE


Coding & OASIS

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Ø Comparison of Clinical Groupings through May 2020

Impact of PDGM and COVID-19 (Continued)

Coding & OASIS

Clinical Group January February March April May YTD 2020MMTA - Other 2.9% 2.9% 2.9% 2.9% 3.1% 3.0%Neuro / Stroke 10.5% 10.6% 10.3% 10.0% 10.3% 10.3%Wound 13.1% 13.7% 14.4% 15.6% 15.0% 14.4%Complex Nursing 3.0% 3.4% 4.0% 4.7% 4.2% 3.9%Musuloskeletal Rehab 21.6% 19.7% 18.5% 15.5% 17.3% 18.4%Behavioral Health 2.6% 2.8% 2.7% 2.8% 2.7% 2.7%MMTA - Surgical Aftercare 4.2% 4.2% 4.5% 3.9% 3.9% 4.1%MMTA - Cardiac 17.2% 17.9% 18.0% 18.5% 18.2% 18.1%MMTA - Endocrine 5.0% 5.2% 5.3% 5.7% 5.6% 5.4%MMTA - GI / GU 5.0% 5.0% 5.1% 5.2% 5.3% 5.1%MMTA - Infectious 5.4% 5.3% 5.3% 5.5% 5.5% 5.4%MMTA - Respiratory 9.5% 9.3% 9.2% 9.6% 8.9% 9.3%


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Ø Comorbidity Adjustments

Ø Functional Impairment Levels

Impacts of PDGM and COVID-19 (Continued)

Coding & OASIS

Comorbidity Adjustment January February March April May YTD 2020

None 50.5% 48.2% 46.7% 45.3% 47.6% 47.5%

Low 36.8% 37.9% 38.7% 39.6% 38.8% 38.4%

High 12.7% 13.9% 14.6% 15.1% 13.6% 14.1%

Functional Impairment January February March April May YTD 2020

None 24.3% 23.2% 23.1% 24.4% 25.3% 24.0%

Low 34.0% 33.0% 32.0% 31.1% 31.4% 32.2%

High 41.8% 43.8% 45.0% 44.4% 43.4% 43.8%


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Ø Preparation for potential increase in OASIS reviews due to patient census increase

Ø OASIS-E future roll-out and education pertaining to changes

Ø Pre-coding potential expansion

Future Predictions

Coding & OASIS

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Documentation Management

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Ø Short turnaround time needed for period 1 billingØ Improvement in turnaround times for signed

orders receipt

Impact of PDGM


Ø Source: Forcura analysis of orders data for period 01/01/19 through 03/11/20 for nearly 200 agencies

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Ø Improvement in percentage of orders returned within one week of submission



Ø Source: Forcura analysis of orders data for period 01/01/19 through 03/11/20 for nearly 200 agencies

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Ø Non-Physician Practitioners (NPP’s) now allowed to certify home healtho Still need to abide by state regulations

Ø Face-to-face encounter can be performed via telehealthØ Inability to leverage liaisons and couriers in orders processØ Varying impacts on physician response times

o In highly impacted regions, hospital physicians more focused on patient care than reviewing home health orders

o In lower impact regions/care settings, physicians seeing a lower volume of patients so have more time to review and sign orders



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Ø Permanent role of NPP’s in home health certification

Ø Facilitation of documentation management process as census stabilizes/increases following PHE

Ø Role of technology continuing to increaseo Includes utilization of telehealth in face-to-face

encounter processo Education of physicians on portals

Ø Oregon state attempting to adopt federal regulations to allow NPP’s to sign patient orders

Future Predictions


Ø https://www.nursepractitionersoforegon.org/page/150

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https://www.nursepractitionersoforegon.org/page/150

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Billing and Collections

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Impact of PDGM


Ø Increase in claims volume with transition from 60-day episode to 30-day periods

Ø Changes in billing requirementso Ex. Updated HIPPS code format

Ø No major Medicare claims processing issues identified

Ø Inconsistency with billing requirements for Medicare Advantage payors

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Ø Increase in processing delays for Medicare Advantage and Commercial claims

Ø Census decrease for agencies has had a direct impact on cash and claim volume

Ø Agencies that billed claims and received remits by paper experienced a more difficult transition to a remote workforce

Ø RAP auto-cancel timeline extended by 90 days

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Future Predictions


Ø New and updated metrics adjusted after several months of PDGM datao Develop updated process to manage new metrics such as LUPA

%’s, Community vs. Institutional, therapy usage, etc.

Ø Lessons learned to decrease Medicare Advantage denial rate

Ø Anticipated increase in overall technology and telehealth usage if Medicare begins to reimburse and count towards LUPA thresholdso Reimbursement for telehealth has been adopted by some MA

payors and is expected to expand

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Cash Flow

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Initial 2020 Impacts

Cash Flow

ØDecrease in cash flow initiallyoJan 2020 Cash Variance compared to Dec 2019 cash: -18%*oFeb 2020 Cash Variance compared to Dec 2019 cash: - 38%

ØReduction of RAP payments to 20%oAgencies certified in 2019 and later receiving no-pay RAPs

ØReview Choice Demonstration (RCD) expanding to additional states

ØPotential pressures on profit marginsoPossible reduction in payment ratesoIncreased costs of doing business

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Impact of COVID-19

Cash Flow

ØCash trended by BlackTree showed an initial stabilization in early March followed by continued decrease due to effects of COVID-19o March 2020 Cash Variance compared to Dec 2019 cash: 0%*o April 2020 Cash Variance compared to Dec 2019 cash: - 7%

ØAccelerated Medicare payments offered in Aprilo Recoupment of funds begins 120 days after receipt

Ø2% sequestration suspended for dates of service 5/1/20 through 12/31/20o Based on dates of service – last billable visit date on the claim

ØCARES Act stimulus fundso Traunch 1 based on Medicare paymentso Traunch 2 based on total revenueo Traunch 3 focus on Medicaid and CHIP providers

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Future Predictions

Cash Flow

ØCash continues to stabilize as census returns to pre-PHE levels

ØContinued elimination of RAPso2021: no payment issued for RAPs, but submission still requiredo2021: 5-day timely filing penalties, but lesser pre-bill

requirementso2022: implementation of Notice of Admission (NOA) at start of

care

ØReturn of sequestration for dates of service starting in 2021

ØPrepare to pay back accelerated payments and potentially stimulus checks originally granted by Medicare

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Financial Reporting

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Impacts of PDGM

Financial Reporting

Ø EMRs developed varying levels of PDGM reportingo Utilization of third-party platforms beneficial if

EMR reporting is lackingØ Update of revenue recognition model to PDGMØ Higher reimbursing categories have increased in

volume compared to pre-PDGM predictionsØ High volume of Early and Institutional periods in

early monthso Anticipated that percentage of Late and

Community periods will normalize in long term

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Impacts of PDGM (Continued)

Financial Reporting

Ø Source: Strategic Healthcare Programs (SHP) analysis of PDGM KPI data for period 01/01/20 through 05/31/20

KPI National Avg. (1/1/20 –3/31/20)

National Avg. (4/1/20 –5/31/20)

LDS Predictions

Institutional 36.20% 27.15% 25.30%

Community 63.80% 72.85% 74.70%

Early 48.60% 34.05% 32.00%

Late 51.40% 65.95% 68.00%

Functional (Low) 23.50% 24.85% 34.40%

Functional (Med) 32.90% 31.25% 33.30%

Functional (High) 43.70% 43.90% 32.30%

Comorbid. (None) 48.30% 46.45% 56.60%

Comorbid. (Low) 37.90% 39.20% 35.10%

Comorbid. (High) 13.80% 14.35% 8.20%

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Impacts of PDGM (Continued)

Financial Reporting

Ø Source: Strategic Healthcare Programs (SHP) analysis of PDGM KPI data for period 01/01/20 through 05/31/20

Clinical Grouping National Avg. (1/1/20 –3/31/20)

National Avg. (4/1/20 –5/31/20)

LDS Predictions

MS_Rehab 19.7% 16.4% 17.0%MMTA_Cardiac 17.8% 18.4% 16.1%Wound 13.9% 15.3% 9.5%Neuro_Rehab 10.5% 10.2% 8.6%MMTA_Resp. 9.3% 9.3% 7.8%MMTA_Infect. 5.4% 5.5% 4.2%

MMTA_Endocrine 5.2% 5.7% 4.4%

MMTA_GI_GU 5.1% 5.3% 4.0%MMTA_Aftercare 4.3% 3.9% 3.6%MMTA_Other 2.9% 3.0% 7.4%Complex Nursing 3.3% 4.5% 1.9%

Behavioral Health 2.7% 2.8% 2.0%

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Financial Reporting

Ø PHE started to skew benchmarks at the point when PDGM benchmarks were first able to be developedo Census/revenue decreaseso Lack of elective surgeries impacting Clinical Groupingso Significant increase in LUPA%

Ø Greater focus on PHE effects/regulatory relief than monitoring of PDGM impactso Tracking of stimulus funds to support appropriate utilizationo Determinations on applying for PPP loan or Medicare

accelerated paymentsØ Need to identify date on which PHE started impacting your

agencyØ Changes to revenue recognition

o Removal of sequestration effective DOS 5/1/20-12/31/20

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Ø Creation of long-term PDGM benchmarks once industry stabilizeso Should data for periods during PHE be excluded?o What role will telehealth expansion play in setting

these long-term benchmarks?

Ø Improved EMR reporting on PDGM KPIs

Ø Development of additional reporting platforms to monitor and analyze PDGM KPIs

Future Predictions

Financial Reporting

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Questions?

Brian HarrisConsulting Director

[email protected](610) 536-6005 ext. 732

Consulting Outsourcing Education

Connor MacfarlaneSenior Consultant

[email protected](610) 536-6005 ext. 714

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Documents

OAHC PDGM New New Normal PowerPoint...ØUpdate of payor matrix with new policies and billing codes Initial Impact of PDGM Intake 4 8/18/20 3 5 ØEarly identification of patient timing