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In addition, prospective payment systems are proving to be effective in reducing costs in an organization’s operations, which is also crucial in terms of the financial performance of a health services provider. Pressure to front-load therapy services within the first 30-day payment period to avoid extending into a second 30-day payment period when the reimbursement is lower. This pressure to frontload services is being applied even though it is not clinically indicated for the patient but rather is driven by a desire to maximize reimbursement or mitigate perceived financial losses. Public and private health insurers, including Medicare, are moving toward alternative payment models in an effort to reduce costs and improve the quality of patient care.
CMS finalized policy changes regarding the use of services furnished via telecommunications systems in the CY 2021 HH PPS final rule. However, the collection of data on the use of telecommunications technology under the home health benefit is limited to a broad category of telecommunications technology costs under administrative costs on the HHA cost report . In the CY 2023 HH PPS proposed rule, CMS solicited comments on the collection of data on the use of such services furnished using telecommunications technology on the home health claims . CMS plans to begin collecting this data on home health claims on a voluntary basis beginning on January 1, 2023 and on a mandatory basis beginning on July 1, 2023. Further program instruction for reporting this information on home health claims will be issued in January, 2023. On January 1, 2020, CMS implemented the home health PDGM and a 30-day unit of payment as required by Section 1895 of the Social Security Act.
Home Health Prospective Payment System (HH PPS) Overview
This revised payment methodology—the Patient-Driven Grouping Model —is driven by the patient’s clinical characteristics rather than amount or types of services provided. While the payment system changed on January 1, 2020, to the PDGM, this system was implemented in a budget neutral manner meaning that the agency receives the same amount of money as it did under the previous system. However, the financial incentives for how the agency uses these funds may shift. For example, the funds could be used for more nursing services than therapy services. The Outcome and Assessment Information Set assessment tool is completed when the patient is admitted.
This payment system aims to provide high-quality services without severe risks to current resources for both clients and medical organizations. Payers have a choice in determining how they pay to ensure that risks are shared fairly. Thus, a situation arises in which the payment system benefits extend to both payers and healthcare service providers.
Home Health Prospective Payment System (HHPPS)
The new Medicare home health prospective payment system pays fixed, predetermined rates for services provided during episodes of home health care. This article details the construction and principal components of the new payment system and shows how episode payment rates and other amounts that Medicare now pays for home health care are calculated. Suggestions are made for steps that home health agencies can take to respond most effectively to the new system's operational requirements and align themselves with the plan's financial incentives. A private practice SLP may treat a Medicare beneficiary in the home once it is confirmed that the patient is not receiving services through a home health agency. SLPs who provide services in patients’ homes are not eligible for reimbursement for travel costs from Medicare or the patient. When submitting claims, use Place of Service Code 11 to reflect that services were delivered in the patient’s home.
PDGM is based on historic claims and OASIS data and according to CMS, this data was often incomplete (e.g.; it lacked comprehensive diagnosis coding including speech-language pathology treatment diagnoses, incomplete OASIS data). The incomplete data prevented CMS from including more conditions which resulted in a payment model that is not reflective of the clinical complexity of patients and their therapy needs. Moving forward, complete and accurate completion of the OASIS and diagnosis coding on claims will be imperative to effectuate changes to PDGM. Additionally, this rule finalizes changes to the Home Health Quality Reporting Program requirements; changes to the Expanded Home Health Value-Based Purchasing Model; and summarizes the input received on the health equity request for information for both HH QRP and HHVBP.
Audiology and Speech-Language Pathology Services
Under APMs, all health care providers—including audiologists and SLPs—are held accountable for the increased quality and lower costs of the care they provide. Changes to the way Medicare pays for services provided in skilled nursing facilities and home health agencies are designed to improve the quality and value of care patients receive. However, the business reaction for implementing these payment systems has the potential for patient harm. ASHA is looking for patient impact stories since PDPM and PDGM were implemented. HHAs must provide the covered home health services either directly or under arrangement, and must bill for such covered home health services.
The current coronavirus situation seriously hampers the provision of medical care for transplantation (de Vries et al., 2020). The transportation of organs was limited due to the high probability of transmission of the virus. Such limitations negatively affected the health of citizens in need of a transplant operation. Recently, the problems of obsolescence of the retrospective payment system compared to the prospective one have also become especially urgent. The decline in hospital attendance due to COVID-19 leads to a decrease in the revenue of healthcare companies. PPS can solve this problem by introducing a prepayment system to keep the income at a stable level.
This rule also discusses the comments received on the best approach to implement the statutorily required temporary payment adjustment for CYs 2020 and 2021, and those comments will be considered for future rulemaking. The Bipartisan Budget Act of included several requirements for home health payment reform, effective January 1, 2020. These requirements included the elimination of the use of therapy thresholds for case-mix adjustment and a change from a 60-day unit of payment to a 30-day period payment rate. The statutorily required provisions in the BBA of 2018 resulted in the Patient-Driven Groupings Model, or PDGM. The PDGM removes the current payment incentive to overprovide therapy, and instead, is designed to focus more heavily on clinical characteristics and other patient information to better align Medicare payments with patients’ care needs.
The OASIS places a patient into a diagnostic category, and the agency receives a payment for all of the services that the patient requires. The services are billed through the agency rather than the individual clinician who rendered the services. Current Procedural Terminology (CPT®) codes are not used for billing purposes under the HH PPS. However, they may be used to track services for administrative and productivity purposes. Each agency has its own criteria for tracking services and determining productivity, but these rules are separate from payment policy. In addition to the usual standard fees for transplant services provided, many healthcare organizations add the cost of additional fees.
In other words, CMS ran actual claims under the prior system and compared it to the claims under the PDGM system, which allowed a comparison of aggregate expenditures under both systems in order to determine the estimated aggregate impact of behavior change. Consolidated billing creates unique challenges for SLPs in private practice who may provide services to Medicare beneficiaries in their homes. When a patient is under a home health plan of care through a home health agency, all therapy services are billed by and paid to the agency and may not be separately billed by the private practice SLP. A private practice SLP may not always be aware that a patient is being cared for by a home health agency and could inadvertently deliver services that are subsequently denied by Medicare because of consolidated billing. In these instances, there is little recourse for the SLP in private practice, as the patient cannot be billed for these services. SLPs in private practice who find themselves in this situation could approach the home health agency for payment, but the agency is under no obligation to reimburse the SLP.
Additionally, Congress mandated that therapy be removed as a determinant of payment and that the current 60-day episodes be split into 30-day payment periods. This obligates CMS to implement two of the key elements of the PDGM, also by 2020. Despite the removal of therapy as a factor in payment, CMS has issued detailed guidance stressing the value of therapy as part of the new payment system.
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It is possible that some patients may not be suitable for treatment by a student, regardless of the level of supervision. Additionally, some students may require a greater degree of supervision than their counterparts with more experience. Differentiate between the prospective payment systems for outpatient, home health, physician and non-physician practitioners, and ambulatory surgical settings. Thankfully, several members of congress have recognized the drastic impact these cuts will have on the industry and the patients in need of home health services. Pressure to pick up as many patients as possible so that the volume of individual patients compensates for the “financial loss” that the volume of visits no longer provides.
Under Medicare, student supervision requirements vary by practice setting and whether services are covered under Part A or Part B of the Medicare benefit. For example, Medicare is explicit that student services under Part B require 100% direct supervision of the licensed SLP. Conversely, Medicare has largely been silent on the level of supervision required under Part A. These cuts are a result of CMS’s efforts to meet a 2018 budget neutrality requirement as part of the transition to the Patient-Driven Groupings Model . While developing the PDGM, CMS was given the ability to make adjustments to the base payment rates to account for behavioral assumptions, causing serious backlash from the industry.
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