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.
Home health (HH) agencies that provide services—including speech-language pathology services—to Medicare beneficiaries are paid under a prospective payment system (PPS) through Part A of the Medicare benefit. HH PPS policies are reviewed and updated annually and are effective for the calendar year (January 1 – December 31). As of January 1, 2020, Medicare pays for home health services via a value-based payment model known as the Patient Driven Groupings Model (PDGM). Under PDGM, many of the policies and regulations dictating the requirements for home health coverage, such as consolidated billing and requirements to provide all medically necessary services to patients, will remain the same. Therefore, it is important to understand how PDGM relates to longstanding requirements that are not changing.
The most significant change under PDGM is that payment is no longer driven by the number of therapy visits provided, instead, payment is based on patient characteristics. This changes the way SLPs demonstrate their value in this setting and could lead to unintended administrative mandates in the way SLPs deliver care to patients. More technical information on PDGM can be found below.
The Centers for Medicare & Medicaid Services (CMS) outlines regulations and guidance related to the home health benefit in Chapter 7 of the Medicare Benefit Policy Manual [PDF] and Chapter 10 of the Medicare Claims Processing Manual [PDF]. Additional policies may be outlined in local coverage determinations from Medicare Administrative Contractors (MACs).
Audiology services are excluded from the HH PPS and may be billed independently by the audiologist under the Part B benefit (Medicare Physician Fee Schedule).
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The Part A home health benefit is paid in 60-day episodes and includes speech-language pathology, physical therapy, occupational therapy, skilled nursing, home health aide, and/or medical social services. The agency is responsible for providing all of the services a patient requires. If a Medicare beneficiary requires fewer than four visits during the 60-day episode, the home health agency will receive a lower payment, known as a low utilization payment (LUPA), to reflect the lower cost of the short episode. (See also: Consolidated Billing)
A critical factor in qualifying for a Part A episode of home health services is a physician’s determination that the patient is confined to the home, or “homebound.” This means the patient has
A patient that is certified as "homebound" may still leave the home for specific reasons, such as attending religious services or going to medical appointments.
Additional requirements to qualify for a Part A episode for home health services are
A continuing need for occupational therapy can maintain eligibility after one of the initial qualifying services listed above terminates.
For each therapy discipline required for the patient, the therapist must assess the patient’s function at the initial visit and reassess function every 30 days. The amount, frequency, and duration of therapy must be reasonable and supported by documentation.
If a Medicare beneficiary does not qualify for the Part A home health benefit, their services may be paid under the Part B benefit through the Medicare Physician Fee Schedule. For example, if the patient is not deemed "homebound" by a physician, the services may be covered under Part B. In these instances, all of the Medicare Part B coverage criteria apply (e.g., multiple procedures payment reduction [MPPR], annual financial limitations on outpatient therapy services). These services could be provided by the home health agency or by a speech-language pathologist (SLP) in private practice.
The Outcome and Assessment Information Set (OASIS) assessment tool is completed when the patient is admitted. 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(s) 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.
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.
Before January 1, 2020, an agency received additional reimbursement based on the number of therapy visits provided to a patient. There has been concern that this payment system may have resulted in some providers or agencies providing medically unnecessary care. Under PDGM, the financial incentives changed, and clinicians may be pressured to restrict service delivery. Regardless of the type of payment system in place, it is critical that services provided are clearly documented and are reasonable, necessary, and individualized to the needs of each patient.
Home health agencies are subject to consolidated billing. This means that the agency must provide and bill for all Part A and Part B services provided to the patient. Consolidated billing is a mechanism established by CMS to prevent double billing for services. For example, if the agency does not have an SLP on staff, they must contract with an SLP to provide the necessary services. In this scenario, the agency would bill Medicare for the SLP’s services and pay the SLP a negotiated rate. CMS does not dictate the amount a contract employee is paid.
To ensure consolidated billing is implemented appropriately, beginning in 2022 home health agencies will need to complete a notice of admission (NOA) within 5 days of admitting a patient to a home health episode or face a reduction in payment. The NOA replaces the request for anticipated payment (RAP) which proved to be an ineffective method for ensuring home health agencies complied with their obligations under consolidated billing.
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.
It is critical that the SLP in private practice does everything they can to confirm that a Medicare beneficiary is not receiving services through a home health agency. An SLP can take the following steps to attempt to determine a patient’s status prior to initiating services:
It is important to note that home health agencies only submit claims once every 60 days. As such, it is possible that the IVR and CWF systems may not yet reflect that a patient is under a home health plan of care. However, patient self-reporting, the IVR, and the CWF are the only systems available at this time to check on the homebound status of a patient. Contact your local MAC to access the IVR or CWF. When the new NOA requirement is made effective in 2022, there will be a financial penalty applied to agencies that do not claim patients in a timely fashion
If a patient under a home health plan of care through a home health agency is not receiving medically necessary speech-language pathology services, they should address this directly by requesting these services through the agency, switching to a different home health agency, and/or lodging a complaint with Medicare.
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.
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.
When determining the appropriate level of supervision of a student, the supervising SLP should consider payer policy, the requirements of the university from which they have received the student intern, state law, ASHA standards, the needs of the patient, and the skills of the student. 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.
Public and private health insurers, including Medicare, are moving toward alternative payment models (APMs) in an effort to reduce costs and improve the quality of patient care. APMs are alternatives to traditional fee-for-service payment. 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. CMS is shifting the HH PPS to an alternative payment model, as outlined below.
In 2018, CMS finalized a major overhaul to the HH PPS to address concerns that a payment system based on the volume of services provided (e.g., therapy visits) creates inappropriate financial incentives. This revised payment methodology—the Patient-Driven Grouping Model (PDGM)—is driven by the patient’s clinical characteristics rather than amount or types of services provided. The PDGM was effective January 1, 2020.
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 [PDF] stressing the value of therapy as part of the new payment system.
In addition to these Congressional mandates, key provisions of the final rule include:
Despite reliance on clinical categories as the driver of payment, Medicare regulations (e.g. conditions of participation) make clear that patients must receive all medically necessary services, regardless of the clinical category to which they are assigned. As stated in the 2019 HH PPS proposed rule [PDF]:
“While these clinical groups represent the primary reason for home health services during a 30-day period of care, this does not mean that they represent the only reason for home health services. While there are clinical groups where the primary reason for home health services is for therapy (for example, Musculoskeletal Rehabilitation) and other clinical groups where the primary reason for home health services is for nursing (for example, Complex Nursing Interventions), home health remains a multidisciplinary benefit and payment is bundled to cover all necessary home health services identified on the individualized home health plan of care. Therefore, regardless of the clinical group assignment, HHAs are required, in accordance with the home health CoPs at § 484.60(a)(2), to ensure that the individualized home health plan of care addresses all care needs, including the disciplines to provide such care.”
ASHA actively engaged in the development of the PDGM through formal written comments, meetings with CMS staff, and with speech-language pathology member representation on technical expert panels to ensure a move to such a payment model represents appropriate clinical practice. However, CMS indicated that there was a lack of data supporting the inclusion of more conditions in the payment model. 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.
Since payment is not driven by the number of therapy visits, SLPs might be instructed to change their practice patterns. SLPs should be willing to assist in the identification of efficiencies to improve the quality of care for patients and to ensure the financial viability of the agency but not at the expense of patient care or in violation of federal laws and regulations and professional ethical standards. Some examples of inappropriate administrative mandates SLPs might encounter under PDGM include:
ASHA has received numerous reports from members indicating HHAs are using predictive analytic tools to dictate the number of therapy visits provided to patients that are not supported by the needs of the patient and the clinical judgment of the therapist. The CEO of one of the major predictive analytic companies has publicly stated that the use of these tools in the absence of the clinical judgment of the therapists is not an appropriate use of the technology.
If you are facing such pressures, it is important to discuss these concerns directly with your leadership (e.g. executive director or nurse manager). If these cannot be resolved internally, you need to consider reporting them to the appropriate oversight bodies, for more information on this process see: ASHA’s Consensus Statement [PDF] and Compliance Reporting [PDF] documents.
Since PDGM was designed to change the payment incentive from volume to value and address concerns regarding overutilization, SLPs may see changes in employment including layoffs, changes in salaries, or changes from full-time to part-time status.
Under PDGM there are several ways you can demonstrate your value to your employer, below are some examples:
See also: Overview of the Home Health Groupings Model [PDF]
In 2014, Congress passed the IMPACT Act in an effort to better understand the differences in payments and outcomes among four post–acute care settings: skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), home health, and long-term care hospitals (LTCHs). The IMPACT Act requires the standardization of data across the four post-acute care settings. Currently, each setting has its own distinct assessment tool (home health agencies use the OASIS). These separate assessment tools do not collect or track data in a consistent manner, making it difficult to evaluate the distinctions between the settings. However, CMS has already begun—and will continue—to change the assessment tools in order to comply with the mandates of the IMPACT Act. The Act also requires reports examining the possibility of implementing a unified PPS across all four settings.
Questions? Contact ASHA’s health care policy team at firstname.lastname@example.org.