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Home Health Revenue CycleNavigating Cash Flow Changes

M. Aaron Little, CPA

Managing Director

BKD, LLP

mlittle@bkd.com

MAHC 2020

MAHC 20202

Intake or update

Initial document-

ation

RAP billed

Document-ation

manage-ment

End of billing period

Claim billed

Collections & reporting

PDGM

PDGM

Compliance COVID-19

MAHC 20203

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PDGM

Compliance COVID-19

MAHC 20204

MAHC 20205

Missouri Estimated PDGM Financial Impact

• Based on 2020 final payment rule

• Negative impact of 10% or more

• 42 (27%) agencies

• Negative impact of 5% to 10%

• 31 (20%) agencies

• Negative impact less than 5%

• 27 (17%) agencies

• Zero or positive impact less than 5%

• 20 (13%) agencies

• Positive impact of 5% to 10%

• 12 (8%) agencies

• Positive impact of 10% or more

• 23 (15%) agenciesNote: Per CMS 2018 claims & OASIS data after

consideration of behavior adjustments

-3.0%

MAHC 20206

January

15% decrease

February

30% decrease

March

Rebound

April/May

New normal

• Your new normal

based on yourPDGM revenue

impact

PDGM Cash Flow Predictions

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MAHC 20207

January

15% decrease

February

30% decrease

March

Some rebound

April/May

????

PDGM Cash Flow Realities

MAHC 20208

Assessing Cash Flow Impact

PDGM factors

Volume

Case-mix weight

- 1.0814 (non-LUPA)*

LUPAs

- 10.3%*

PDGM periods per patient

- 2.2 (non-LUPA)*

Billing timing

- 10 to 12 days for RAPs & claims

COVID-19 factors

Decreased patient volume

Decreased visit volume

Reduced access to physicians

Workforce disruptions

Technology disruptions

*Per CMS 2018 claims & OASIS data for Missouri home health agencies

PDGM Revenue Cycle Key Issues

MAHC 20209

Decreased RAP payments

Operational issues

Claim processing issues

EMR issuesPDGM revenue impact

MA issues

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PDGM Revenue Cycle Key IssuesRAP Payments

MAHC 202010

Decreased RAP payments

• 30-day payment period vs. 60-day

payment period

• 20% or 0% RAP payment percentage

vs. 60% or 50% RAP payment

percentage

PDGM Revenue Cycle Key IssuesOperational Issues

MAHC 202011

Operational issues

• Post-acute inpatient stays

• Mid-episode coding

• Physician order management

PDGM Revenue Cycle Key IssuesOperational Issues – Post-acute Inpatient Stays

MAHC 202012

ROC vs. Discharge/Readmit

Patient admitted to HH 01/01/20 with no prior inpatient stays

Patient admitted to hospital 01/10/20 & discharged to SNF 01/13/20

Patient returns to HH 01/20/20 after discharge from SNF 01/18/20

Operational policy?

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• Option 1 – ROC

• $3,232 total payment for two payment periods

• Cost considerations

• Episode & payment periods proceed as planned

• Possible additional costs due to change in care

• Process & policy considerations

• Are clinical personnel clear on expectations?

• Option 2 – Discharge & readmit

• $2,547 total payment for two payment periods

• Cost considerations

• New SOC, OASIS, POC & possibly new FTF encounter documentation

• Possible additional costs due to change in care

• Process & policy considerations

• Are clinical personnel clear on expectations

MAHC 202013

PDGM Revenue Cycle Key IssuesOperational Issues – Post-acute Inpatient Stays

MAHC 202014

PDGM Revenue Cycle Key IssuesOperational Issues – Mid-episode Coding

1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30 31 | | | 35 | | | | 40 | | | | 45 | | | | 50 | | | | 55 | | | | 60

Period 1 Period 2

Coding &/or admission

source updates & FBV

scheduling

Goal: days

to bill

Period 2

RAP

Goal: days

to bill

Period 1

RAP

• Requires routine process for evaluating whether new diagnosis codes are required for Period 2• New OASIS required or already documented?

• Utilize EMR features to manage process

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PDGM Revenue Cycle Key IssuesOperational Issues – Physician Order Management

1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30 31 | | | 35 | | | | 40 | | | | 45 | | | | 50 | | | | 55 | | | | 60

Period 1 Period 2

Intake, FTF,

OASIS, POC,

coding, etc.

Coding &/or

admission source

updates & FBV

Period 1 Timing Variables

• FTF, OASIS, POC & coding (RAP)

• Physician signatures (claim)

• POC

• Physician FTF encounter

documentation• Interim orders, if applicable

Period 2 Timing Variables

• Coding &/or admission source updates &

scheduling FBV (RAP)

• Physician signatures (claim)

• POC

• Physician FTF encounter documentation

• Interim orders, if applicable

Physician order management

Goal: days

to bill

Period 1

RAP

Goal: days

to bill

Period 2

RAP

Goal: days

to bill

Period 1

claim

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MAHC 202016

PDGM Revenue Cycle Key IssuesOperational Issues – Physician Order Management

Example Agency

PDGM Revenue Cycle Key IssuesClaim Processing Issues

MAHC 202017

Claim processing issues

• Claims billed must match accepted

OASIS on file in iQIES

• Numerous errors resulting in claim RTPs

• New payment validation process

PDGM Revenue Cycle Key IssuesClaim Processing Issues

MAHC 202018

IntakeBeneficiary data input into EMR

OASIS completed

OASIS submitted to & accepted by

iQIESRAP billed Claim billed

Error occurs

Error revealed

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PDGM Revenue Cycle Key IssuesClaim Processing Issues

MAHC 202019

OASIS• Must be accepted by iQIES

before claim is billed

✓ M0100 RFA 01, 03, 04 or

05

✓ M0010 CMS certification number

• Data required to match

between OASIS and claim

✓ M0063 MBI

✓ M0090 assessment completion date

Claim• Must be billed after OASIS is

accepted by iQIES

✓ Data MBI

✓ Occurrence code 50

date must agree to OASIS M0090 date

• Required to match between

OASIS and claim

Match

• Avoid claim reason code 37253 for “no matching assessment”

• Recent CMS resource SE20010 dated 03/09/20

PDGM Revenue Cycle Key IssuesClaim Processing Issues

MAHC 202020

Billed HIPPS code

Admission source

• CWF vs. occurrence codes 61/62

Admission timing

• CWF

Clinical grouping

• Claim primary diagnosis

Functional impairment level

• Occurrence code 50

• Most recent OASIS

• iQIES validation

Comorbidity adjustment

• Claim other diagnosesPaid HIPPS code

Payment adjustments

• LUPA

• PEP

• OutlierPaid claim amount

PDGM Revenue Cycle Key IssuesClaim Processing Issues

MAHC 202021

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PDGM Revenue Cycle Key IssuesEMR Issues

MAHC 202022

EMR issues

• Community vs. institutional status errors

• Early vs. late status errors

• Functional impairment errors

• Revenue calculation errors

• Data interface errors

• MA PDGM claim coding errors

PDGM Revenue Cycle Key IssuesPDGM Revenue Impact

MAHC 202023

PDGM revenue impact

• Functional impairment level

• Length of service

PDGM Revenue Cycle Key IssuesPDGM Revenue Impact – Functional Impairment Level

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Admission source & timing

Clinical grouping

Functional impairment level

Comorbidity adjustment

OASIS accuracy

MAHC 2020

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0.9962

Agency A

MS Rehab

Average case-mix weight*

*Excludes LUPAs

0.9230

Agency B

MS Rehab

Average case-mix weight*

23%

77%

Institutional*

Community*

1%

99%

Institutional*

Community*

61%

39%

Late*

Early*

84%

16%

Late*

Early*

24%

26%

50%

High*

Medium*

Low*

43%

39%

18%

High*

Medium*

Low*

11%

30%

59%

High

Low

None

5%

29%

66%

High

Low

None

Clinical outcome sustainable?

PDGM Revenue Cycle Key IssuesPDGM Revenue Impact – Length of Service

26 MAHC 2020

1 | | | 5 | | | | 10 | | | | 15 | | | | 20 | | | | 25 | | | | 30 31 | | | 35 | | | | 40 | | | | 45 | | | | 50 | | | | 55 | | | | 60

Period 1 Period 2

Discharge =

Payment for

one period

Discharge =

Payment for

one period+

Discharge =

Payment for

one period+

• $1,923 avg. payment per period*• $2,223 avg. payment per period + LUPA*• $3,846 avg. payment for two periods*

*Per CMS LDS data for Missouri agencies per 2020 final payment rule.

PDGM Revenue Cycle Key IssuesMA Issues

MAHC 202027

MA issues

• PPS vs. PDGM HIPPS code

• Occurrence code “50” vs. OASIS

matching string

• Increased payment cycles

• Audit/reconciliation of admission

source & timing?

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PDGM

Compliance COVID-19

MAHC 202028

Compliance Issues

MAHC 202029

RAC audits

CERT audits

RCD TPE

Compliance IssuesRAC Audits

MAHC 202030

RAC audits

• Performant

• Conducts nationwide post-pay medical review for home health, hospice & DME

• Three-year period

• All issues approved by CMS & published on RAC website

• Limitations to amount of review focused on single provider

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MAHC 202031

RAC

activity

paused

during

PHE

Compliance IssuesCERT Audits

MAHC 202032

CERT audits

• Monitors accuracy of claim payments

across Medicare programs by conducting

post-pay medical review

• Publishes results annually

MAHC 202033

Compliance IssuesCERT Audits

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MAHC 202034

Compliance IssuesRCD

MAHC 202035

RCD• Five-year Medicare home health

demonstration project

• Includes all home health providers in

selected states assigned to PGBA

• Requires intensive scrutiny through pre-

or post-pay medical review

MAHC 202036

05/04/20DELAYED

03/02/2006/01/19 09/30/19

05/04/20DELAYED

RCD paused during PHE…BUT subject to post-pay review after PHE!

RCD implementation delayed due to PHE

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Compliance IssuesTPE

MAHC 202037

TPE• Provider-specific pre-pay medical review

• CGS typically selecting 20 claims per

round

• CGS typically using 25% payment error

rate threshold

TPE paused during PHE

MAHC 202038

Provider selected for TPE

Letter issued by MAC informing provider of TPE

One round of 20 to 40 claims selected for prepay medical

review

Letter issued by MAC informing provider of TPE

results

Depending on TPE results two

additional rounds could occur

MAC offers provider education after each round of

TPE

Good Outcome

TPE discontinued for at least 12

months

Bad Outcome

MAC refers provider to CMS for

additional action

????

MAHC 202039

????

What does a “referral to CMS”

mean????

• “Frequently” means additional round(s) of TPE…

• …but, could mean

• 100% pre-pay review

• Extrapolation

• Referral to a RAC

• Referral for revocationSource: CMS CR 11695

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MAHC 202040

TPE Review Topic Description

Eligibility & medical necessity

This edit selects providers who submitted claims with errors as identified in probe and educate round two

Length of stay with hypertension

This edit selects claims for providers who submitted diagnosis hypertension and a length of stay greater than 120 days

No response to ADR This edit selects providers who fail to respond to ADRs

Low visit utilization This edit selects claims for providers who submit only five visits in a 60 day episode

Length of stay >120 days

This edit selects claims for providers who submit claims with a length of stay greater than 120 days

Length of stay >180 days

This edit selects claims for providers who submit claims with a length of stay greater than 180 days

New providers This edit selects claims for relatively new providers who have submitted at least 50 claims

Source: CGS

MAHC 202041

Source: CGS

Compliance IssuesTPE

MAHC 202042

FTFPhysician

orders

Homebound status

Medical necessity

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Compliance IssuesTPE – FTF

MAHC 202043

POC

• Signed & dated by

certifying physician

• Home health certification statement

• FTF certification statement including date of qualifying

encounter

Encounter

• Signed & dated by

physician or NPP who performed qualifying encounter

• Encounter date matches

date of qualifying encounter indicated on

POC

• Related to reason for

home health

• Supports skilled need & homebound status

Home Health Excerpt

• Supports skilled need &

homebound status

• Signed & dated by certifying physician acknowledging

acceptance into physician’s medical record

Compliance IssuesTPE – FTF – Example 1

MAHC 202044

POC

• Signed & dated by

certifying physician

• Home health certification

statement

• FTF certification statement including date of qualifying

encounter

• 12/31/20

Encounter

• Encounter date

documented as

• 12/29/20

Compliance IssuesTPE – FTF – Example 2

MAHC 202045

POC

• Signed & dated by

certifying physician

• Home health certification statement

• FTF certification statement including date of qualifying

encounter

Encounter

• Unrelated to primary

reason for home health services

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Compliance IssuesTPE – FTF – Example 3

MAHC 202046

POC

• Signed & dated by

certifying physician

• Home health certification statement

• FTF certification statement including date of qualifying

encounter

Encounter

• Document unsigned &/or

undated by physician or NPP who performed qualifying encounter

Compliance IssuesTPE – FTF – Example 4

MAHC 202047

POC

• Signed & dated by

certifying physician

• Home health certification

statement

• FTF certification statement including date of qualifying

encounter

Encounter

• Documentation does not

support skilled need or

homebound status

Compliance IssuesTPE – Physician Orders

MAHC 202048

Order for every visit

Visit for every order

Signed & dated by physician prior to billing

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PDGM

Compliance COVID-19

MAHC 202049

COVID-19

MAHC 202050

RAP auto-cancellations

OASIS reporting

Sequestration

Telecommunications

NPPs

Funding sources

COVID-19

MAHC 202051

RAP auto-cancellations

OASIS

Sequestration

Telecommunications

NPPs

Funding sources

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COVID-19RAP Auto-cancellations

MAHC 202052

PDGMRAP billing period end

date (day 30)60 days

Auto-cancellation

PHERAP billing period end

date (day 30)60 days 90 days

Auto-cancellation

COVID-19

MAHC 202053

RAP auto-cancellations

OASIS reporting

Sequestration

Telecommunications

NPPs

Funding sources

COVID-19OASIS Reporting

MAHC 202054

PDGM

Comprehensive assessment (SOC, ROC, recertification,

other follow-up OASIS)

5 days to complete30 days to transmit to

iQIES but before billing claim

PHE waiver

Comprehensive assessment (SOC, ROC, recertification,

other follow-up OASIS)

30 days to completeTransmit to iQIESbefore billing claim

Source: CMS Flexibilities to Fight COVID-19

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COVID-19

MAHC 202055

RAP auto-cancellations

OASIS reporting

Sequestration

Telecommunications

NPPs

Funding sources

COVID-19Sequestration

MAHC 202056

2% payment reduction for sequestration

Claims with service dates May 1 – December 31,

2020

Source: CMS MLN Matters Special Edition April 10, 2020

COVID-19

MAHC 202057

RAP auto-cancellations

OASIS reporting

Sequestration

Telecommunications

NPPs

Funding sources

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COVID-19Telecommunications

MAHC 202058

Source: CMS Flexibilities to Fight COVID-19

Telehealth two-way audio/visual

Telephone calls

Remote patient monitoring

COVID-19Telecommunications

MAHC 202059

Source: CMS Flexibilities to Fight COVID-19

Must be ordered on POC

Does not replace needed in-person visits

Cannot be billed on Medicare

claims

COVID-19

MAHC 202060

RAP auto-cancellations

OASIS reporting

Sequestration

Telecommunications

NPPs

Funding sources

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COVID-19NPPs

MAHC 202061

Source: CMS Flexibilities to Fight COVID-19

NPPs

Nurse practitioner

Clinical nurse specialist

Physician assistant

Effective March 1, 2020

Order home health services

Establish & review home health POCs

Certify & recertify home health eligibility

COVID-19

MAHC 202062

RAP auto-cancellations

OASIS reporting

Sequestration

Telecommunications

Non-physician practitioners

Funding sources

COVID-19Funding Sources

MAHC 202063

Accelerated/ advance payments

PPP loanCARES Act distributions

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MAHC 202064

Accelerated/ advance payments

• Available upon request from MAC

• Payment advance of up to three months of Medicare revenues

• Recouped against claims automatically after 120 days

• New requests no longer being accepted as of April 26

COVID-19Funding Sources

MAHC 202065

COVID-19Funding Sources – Accelerated/Advance Payments

April:

• $500,000 Medicare payments, plus

• $1.5 million advanced payment

May:

• $500,000 Medicare payments

June:

• $500,000 Medicare payments

July:

• $500,000 Medicare payments

August:

• $500,000 Medicare payments

September:

• $500,000 Medicare net reimbursement

• $0 cash

October:

• $500,000 Medicare net reimbursement• $0 cash

November:

• $500 Medicare net reimbursement

• $0 cash

MAHC 202066

PPP Loan

• Loan available by application through SBA lenders

• Loan targeted at 8-week period of expenses for payroll, rent, mortgage interest & utilities

• Loan maturity of two years & interest rate of 1%

• Loan forgiveness available under certain terms

COVID-19Funding Sources

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MAHC 202067

CARES Act distributions

• Established $100 billion relief fund for health care providers

• $50 billion general distribution issued by HHS in two waves

• April 10/17 & 24

• Requires acceptance of terms & conditions

COVID-19Funding Sources

MAHC 202068

• Distributions available to offset

COVID-19-related lost revenues &

expenses

• Must be documented

• Subject to potential audit

• Distributions over $150,000 subject to

quarterly HHS reporting requirements

COVID-19Funding Sources

PDGM predictions

PDGM realities

COVID-19 impact

MAHC 202069

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bkd.com/HC | @bkdHC

M. Aaron Little, CPA

Managing Director

BKD, LLP

mlittle@bkd.com

Acronyms

MAHC 202072

• ADR Additional development request

• CARES Act Coronavirus Aid, Relief, & Economic Security Act

• CERT Comprehensive Error Rate Testing

• CMS Centers for Medicare & Medicaid Services

• COVID-19 Coronavirus disease 2019

• DME Durable Medical Equipment

• EMR Electronic medical record

• FTF Face-to-face

• FBV First billable visit

• HHS United States Department of Health & Human Services

• HIPPS Health insurance PPS

• iQIES Internet Quality Improvement & Evaluation System

• LDS Limited data set

• LUPA Low Utilization Payment Adjustment

• MA Medicare Advantage

• MAC Medicare Administrative Contractor

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Acronyms

MAHC 202073

• MBI Medicare Beneficiary Identifier

• NPP Non-physician practitioner

• OASIS Outcome & Assessment Information Set

• PDGM Patient Driven Groupings Model

• PGBA Palmetto GBA

• PHE Public health emergency

• PPP Paycheck Protection Program

• POC Plan of care

• PPS Prospective Payment System

• RAC Recovery Audit Contractor

• RAP Request for anticipated payment

• RCD Review Choice Demonstration

• ROC Resumption of care

• RTP Return to provider

• SBA Small Business Administration

• SOC Start of care

• TPE Targeted Probe & Educate

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