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CPAs & ADVISORS
Lessons Learned From
Pre-Claim Review
Shifting Gears fromPPS to PDGM
Raymond BellesManaging [email protected]
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30-DayPaymentPeriods
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PPS
❑60-day episode for both documentation & payment purposes
PDGM
❑60-day episode for documentation purposes continues
❑30-day periods for payment purposes
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NationalStandard
Payment Rate
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PPS
❑$3,154a national standard 60-day episode payment rate
❑$15 to $570a non-routine supply (NRS) payment add-on per 60-day episode based on OASIS assessment
PDGM
❑$1,874 estimated proposed national standard 30-day period payment rate needed for budget neutrality❑Before 6.42% decrease for
diagnosis coding & low utilization payment adjustment (LUPA) behavioral adjustments
❑Actual rate to be set in 2020 payment rule
a2019 PPS rates
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PDGM Payment Elements
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ClinicalGrouping
(from claims)
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PPS
❑One of three clinical severity levels based on 13 OASIS assessment items❑Low
❑Moderate
❑High
PDGM
❑One of 12 clinical groupings based on diagnostic category of principal diagnosis billed on claim
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FunctionalImpairment
Level(from OASIS)
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PPS
❑One of three functional severity levels based on six OASIS assessment items❑Low
❑Moderate
❑High
PDGM
❑One of three functional impairment levels based on eight OASIS assessment items & diagnostic category of principal diagnosis billed on claim❑Low
❑Medium
❑High
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ComorbidityAdjustment
(from claims)
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PPS
❑No comparative payment element
PDGM
❑Application of a comorbidity adjustment based on qualifying other diagnoses billed on claim
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Case-mixweights
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PPS
❑153 possible case-mix weights for each 60-day episode❑0.4691a low
❑2.0228a high
PDGM
❑432 possible case-mix weights for each 30-day payment period❑0.4784 low
❑1.8586 high
a2019 case-mix weights
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LUPAs
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PPS
❑Per-visit payment applied to any 60-day episode with less than five total visits
PDGM
❑Per-visit payment applied to any 30-day period with total visits ranging from less than two to less than six❑LUPA threshold unique to
each case-mix weight
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Missouri Estimated PDGM Financial Impacta
aEstimated by Centers for Medicare & Medicaid Services (CMS) using 2017 claims data
Estimated
Actual Actual Estimated Estimated Payment
Number 60-day 60-day 30-day Payment Change
of PPS PPS Payment Under Under
Agency Characteristics Agencies Episodes Payment Periods PDGM PDGM
All Missouri agencies 163 85,189 231,570,545$ 131,954 223,598,837$ -3.4%
Freestanding agencies 126 67,128 186,851,012$ 105,980 178,944,694$ -4.2%
Facility-based agencies 37 18,061 44,719,533$ 25,974 44,654,143$ -0.1%
For-profit agencies 86 39,174 115,196,046$ 65,773 108,312,337$ -6.0%
Government owned agencies 26 5,247 13,584,484$ 7,400 12,970,069$ -4.5%
Non-profit agencies 51 40,768 102,790,015$ 58,781 102,316,430$ -0.5%
Rural agencies 61 15,829 40,790,603$ 24,874 39,505,261$ -3.2%
Urban agencies 102 69,360 190,779,942$ 107,080 184,093,575$ -3.5%
Lowest nursing visits 75 31,347 94,942,301$ 49,937 84,955,932$ -10.5%
Next lowest nursing visits 48 44,161 113,740,939$ 66,605 113,813,501$ 0.1%
Second highest nursing visits 26 7,696 18,262,559$ 11,919 19,388,611$ 6.2%
Highest nursing visits 14 1,985 4,624,746$ 3,493 5,440,793$ 17.6%
20aEstimated by CMS using 2017 claims data
Missouri Estimated PDGM Financial Impacta
• Negative impact of 10% or more
• 43 agencies
• Negative impact of 5% to 10%
• 31 agencies
• Negative impact less than 5%
• 27 agencies
• Positive impact
• 62 agencies
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• Freestanding
• For profit
• Urban
• Missouri
• $2.7 million annual Medicare revenues
• 11.5% estimated payment increase under PDGM*
Agency A
• Freestanding
• For profit
• Urban
• Missouri
• $2.3 million annual Medicare revenues
• 11.5% estimated payment decrease under PDGM*
Agency B
*Per CMS estimated provider-specific PDGM financial impact
MANAGING SHORTER PAYMENT PERIODS23
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Current PPS
Proposed PDGM
Front-loaded visits Tapered visits
Front-loaded visits Tapered visits
Full 30-day payment LUPA??
CPAs & ADVISORS
Lessons Learned From
Pre-Claim Review
Shifting Gears fromPPS to PDGM
Raymond BellesManaging [email protected]
