When it comes to its most talked-about provisions, the US Centers for Medicare and Medicaid Services' (CMS) final rule for home health payment under Medicare isn't much of a change from the proposed version released earlier this year, meaning that an entirely new payment system will indeed be rolled out beginning January 1. But other parts of the rule have been tweaked—and in several areas, those tweaks represent wins for the physical therapy profession and the patients it serves in home health settings. [In addition to the lengthy final rule, CMS also offers a fact sheet summary.]
It's official: PDGM is on for 2020.
There wasn't much debate about whether this would happen, but the final rule eliminates any doubt: the Patient-Driven Groupings Model (PDGM) will be the system under which CMS pays home health agencies (HHAs). It's a big change, and APTA offers extensive information on the details of the model, but the bottom line is that the PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The system classifies episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. CMS says it will monitor how HHAs are operating under the PDGM, including the provision of therapy services.
Overall payments will increase by 1.3%.
CMS projects an annual increase of about $250 million in payments related to home health.
"Behavioral adjustments" will still be used—but they won't be as large as proposed.
In anticipation of the possibility that HHAs will alter their practices to maximize payment under the PDGM, CMS had proposed a "behavioral adjustment" that reduced payments by 8.01%. The final rule lowers the negative adjustment to 4.36%.
PTAs will be able to perform maintenance therapy under the home health benefit.
The final rule follows through on an APTA-supported proposal to allow physical therapists assistants (PTAs) and occupational therapy assistants (OTAs) to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the PTA or OTA, the qualified therapist still would be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days.
A question about pain still will be available to patients.
In addition to removing a quality-reporting measure on to pain interfering with activity from the Quality Reporting Program, CMS also proposed eliminating a home health consumer survey question about whether the patient and provider had discussed pain in the past 2 months. APTA and other organizations pressed for that question to remain, and CMS relented. The pain interfering with activity quality measure has been removed, however.
Split payments are going away, and Requests for Anticipated Payment (RAPs) will be gone by 2022—but a modified RAP process will be in place beginning in 2021.
CMS is phasing out the split percentage payment approach beginning in 2020. The split percentage payment amount, paid in response to a RAP, will shift from an upfront 60%-initial, 50%-subsequent payment for each 60-day period to 20% for both initial and subsequent 30-day periods of care. Then, beginning in 2021, there will be no upfront payment made in response to a RAP; however, all HHAs will be required to submit a "no-pay” RAP every 30 days to alert the claims processing system that the beneficiary is under a home health period of care. HHAs must submit the “no-pay” RAP within 5 calendar days of each 30-day period or be subject to a late penalty. Beginning in 2022, CMS will eliminate RAPs and instead require HHAs to submit a Notice of Admission (NOA) every 30 days; agencies must do so within 5 calendar days of each 30-day period or be subject to a payment penalty. CMS says that because they are removing upfront payment associated with the RAP, the agency is relaxing the information needed to submit the “no-pay” RAP and subsequent NOA.