What SLPs Need to Know About the New Medicare Home Health Payment Model

PDGM Facts and Details

Home health agencies (HHAs) implemented the Patient Driven Grouping Model (PDGM) for Medicare reimbursement on January 1, 2020. PDGM bases payment for patients with speech-language pathology needs on their clinical characteristics. Here’s what speech-language pathologists (SLPs) need to know!

PDGM Does Not Dictate Staffing Changes

Under the previous payment model (resource utilization groups, or RUGs), payment was driven by the number of therapy visits provided. Some HHAs manipulated treatment time to maximize reimbursement. HHAs that provided excess therapy may have struggled to manage staffing after the transition to PDGM because they had disproportionately inflated their staffing needs.

While payment reductions have been imposed since the implementation of PDGM, these were implemented because payment to HHAs significantly exceeded the cost of delivering care to patients. In other words, PDGM did not limit or eliminate payment for speech-language pathology services, and assertions to the contrary are inaccurate. As a result, some of the layoffs or reductions in hours experienced by SLPs working in HHAs were a result of administrative choices, not Medicare requirements.

HHAs that planned for the transition to PDGM, appropriately assessed the role of SLPs, and implemented appropriate therapy service delivery methods have been able to maintain appropriate staffing and leverage the expertise of SLPs.

Because PDGM pays based on individual patient characteristics, not by counting the number of visits, accurate, comprehensive coding of all appropriate diagnoses ensures accurate payment to the HHA. SLPs play a critical role in identifying patients who would benefit from skilled services for speech, voice, swallowing, language, and/or cognitive disorders.

Patient Needs—Not Therapy Visits—Drive Payment

PDGM pays based on clinical characteristics of patients, such as diagnosis and comorbidities. Under the previous system (resource utilization groups, or RUGS), payment was driven by the number of therapy visits. This volume-based model incentivized some HHAs to provide maximum treatment time, even when it wasn’t clinically indicated. Under PDGM, some HHAs now mandate providing as little therapy as possible.

ASHA members report that certain HHA employers may limit patient access to speech-language pathology services under PDGM and justify these limitations based on “Medicare requirements.” Employers who indicate that Medicare does not pay for speech-language pathology for a particular diagnosis are not being transparent about their rationale. It is important for SLPs to know that these mandates are not Medicare requirements—they are set by the HHA administration or contract therapy company.

Medicare does not limit evaluations or treatment session amounts, frequencies, or durations. If an administrator takes action to limit any of these variables, SLPs can reinforce the ethical and legal obligation to provide therapy based on the skilled, clinical needs of the patient.

Medicare does not dictate how scores for screening tools, included in the OASIS, such as the Brief Interview for Mental Status (BIMS), are used in making care decisions. Medicare also does not use artificial cutoffs in OASIS scores for coverage and payment decisions and expects that all medically necessary therapy services are provided. As a screening tool, BIMS is one way to help identify a patient’s needs. But it does not stand alone. Screening results are considered in the full context of the patient’s medical record and evaluation by the HHA’s multidisciplinary care team.

Medicare Does Not Dictate Who Can Perform Therapy

Each facility makes determinations on how to use therapy clinicians in compliance with state licensing laws. If an administrator states that Medicare no longer allows SLPs to perform certain types of services, it’s not accurate. For example, Medicare does not dictate cognition or swallowing services can only be provided by occupational therapists or SLPs.

Medicare Does Not Require Mandatory Evaluations for Every Patient

A brief assessment or screen can help you determine if a patient needs a full evaluation. Your clinical judgment and the needs of the patient remain paramount in the decision-making process. Administrative policies that mandate an evaluation and at least one treatment are inappropriate, unethical, and fraudulent when not clinically necessary.

Medicare Has Not Changed the Underlying Obligation That HHAs Must Provide All Medically Necessary Services to Patients

In the home health prospective payment system proposed rule for calendar year 2020, CMS clarified its expectations: HHAs must deliver all medically necessary services to patients, regardless of a patient’s clinical grouping. CMS explicitly stated:

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.

Medicare’s Quality, Safety and Oversight group has determined that the lack of individualized plans of care in home health is in the top 10 reasons for a citation by a state survey agency. These citations can lead to a number of negative consequences, including civil monetary penalties. Ensuring that patient needs are identified and plans of care are individualized to meet those needs further reinforces that HHAs must provide all medically necessary services to their patients.

Medicare Will Pay for Therapy Services Regardless of the Source of Admission (e.g., Community or Institution)

PDGM includes payment for therapy services for patients admitted from either an institution (e.g., hospital) or the community. In reviewing 30-day periods of care for patients with an institutional admission source, CMS found that such patients have higher resource use than those patients admitted from the community. During the first 30 days of the home health episode, CMS pays a higher rate for an institutional admission than for a community admission.

Medicare Pays for a Full 60-Day Episode of Care

Although CMS reduces payment after the first 30-day payment period, payment continues across the entire 60-day episode. SLPs deliver care based on patient needs. There are times that the SLP can complete care during the first 30-day payment period; however, care continues for up to 60 days when needed. Physicians may recertify some patients for subsequent 60-day episode(s) based on their continued need for skilled services.