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HCA Comments on Home Health Rule, PDGM

HCA Vice President for Finance and Management Patrick Conole yesterday sent comments to the U.S. Centers for Medicare and Medicaid Services (CMS) on its proposed 2020 payment rule for home health.

The proposed rule includes updates on a mix of longstanding payment-related programs and structures, alongside the major structural overhaul known as the Patient-Driven Groupings Model (PDGM).

CMS is expected to finalize the rule, following the comment period, in November, with the rule going into effect on January 1, 2020.

PDGM Behavioral Adjustment

Our comments lead by addressing the most prominent part of the proposed rule: PDGM. Top among our concerns are the “behavioral adjustment” cuts that “establish a target for gaming behavior.” These adjustments have not been adequately described or modeled for providers or associations, despite wielding a stunning 8.01 percent cut at the outset of PDGM.

These cuts are a continuing target for redress in legislation that HCA and partners are pushing for passage this fall. Our comments to CMS call for a full description and disclosure of the “behavioral adjustment” methodology without which the total withdrawal of these adjustments is imperative.

RAP proposal

HCA also strongly rejects CMS’s proposal on Requests for Anticipated Payment (RAPs), which would reduce RAP payments to 20 percent in 2020 and eliminate them entirely for 2021. RAPs are vital to an agency’s cash-flow in order to initiate services, especially given upfront documentation burdens that otherwise constrain timely reimbursement.

CMS should withdraw its RAP proposal, which was ostensibly advanced for fraud-detection reasons, and instead focus on other indicators of fraud such as “anomalous volume and timing changes that may be a ‘red flag’ of abusive behavior” using predictive analytics and other more surgical approaches, we argue.

Other PDGM, New Proposals

HCA also addresses issues with the intricacies of the new PDGM model such as the case-mix adjustments based on admission source, which create new and unintended incentives and are a “poor substitute for measures based on patient characteristics.”

Meanwhile, CMS’s proposal to require a home health notice of admission (NOA) — akin to the hospice notice of election (NOE) — creates a whole new set of burdens, problems and unrealistic timetables, especially in coordination with the existing plan-of-care requirements and given the lag times before Medicare Advantage eligibility or authorization information is available to providers on the Common Working File (CWF).

Longstanding issues

HCA also addresses longstanding concerns on the following: The face-to-face requirement, left unchanged in this proposed rule; the inadequacy and inconsistencies of the wage index classifications (which do not adequately reflect market conditions in many locales); the need for extension and refinements to the rural add-on tiers; vendor software and Medicare Administrative Contractor (MAC) readiness concerns for the roll out of PDGM; some considerations on the inclusion of new measures in the Home Health Quality Reporting Program; and other items.


As reported in yesterday’s edition of our Situation Report newsletter, HCA’s Executive Vice President for Clinical and Program Affairs Rebecca Fuller Gray and Lauren Ford, HCA’s Director of Program Research, Development and Policy, are in Washington today for further work with the Council of State Home Care Associations and to conduct legislative visits on PDGM-related legislation and other federal priorities.

This week’s meetings with Congress follow a letter that HCA President and CEO Al Cardillo is circulating individually to every member of New York’s Congressional Delegation urging their co-sponsorship and support for a bill (H.R. 2573) which would overturn the approach to “behavioral adjustment” cuts under PDGM in favor of a more rational, retrospective, and surgical construct for rate adjustments.

You can help by joining us in this call to action on H.R. 2573 using the campaign on our Legislative Action Center here. Please write Congress today!

PDGM-readiness for your clinicians

Last week’s HCA Senior Financial Managers Retreat provided insights on PDGM finance issues. By popular demand, we are also sponsoring a second session on issues to support the readiness of your clinicians and quality directors for PDGM.

As noted by one participant from our previous session of the program, it “was by far the best PDGM education session I have participated in … I left with real action plans to implement within my agencies!”

Please register today for HCA’s PDGM Bootcamp for Clinical Managers and Quality Staff on October 23 in Fairport, near Rochester.