Given the lasting impacts of the Patient-Driven Groupings Model (PDGM) on the home health industry, employing the most efficient processes for documentation, diagnosis coding and OASIS accuracy are vital to keep your revenue cycle operations on track and to optimize reimbursement. 

In a recent Netsmart + McBee webinar moderated by Vice President and McBee Chief Nursing Officer Jeri Ann Kelly, industry experts Karen Tibbs, McBee director of OASIS quality assurance, and Matthew McGowan, McBee advisory consulting manager, shared strategies for bolstering your revenue cycle under PDGM. (See link below.)

1. Eliminate gaps in referrals/intake

While the intake process prepares the patient for the clinician to complete a comprehensive assessment, it also prepares that patient for a clean claim.

During this process, revenue risks can arise via capture of incorrect demographics, invalid face-to-face (F2F) and incomplete insurance verification and eligibility. If not mitigated, these risks can translate into financial consequences, including decreased conversion percentage, delayed billing and denials.

How to mitigate these risks

• Designate specific staff educated on agency payers
• Maintain up-to-date checklists for all steps
• Conduct welcome calls to verify information and scheduling
• Employ a clinical and clerical staffing model

2. Streamline comprehensive assessment process

This physical assessment supports payer eligibility, sets the foundation for managing that episode and, most importantly, determines the reimbursement you will receive.

In this assessment, incomplete OASIS collection, clinical documentation and insurance and eligibility verification can negatively impact your revenue, resulting in case mix inaccuracies, denials and compliance risk.

How to mitigate these risks

• Create an F2F addendum checklist
• Hold timely additional discipline evaluations with collaboration
• Establish and maintain clinician OASIS competency
• Enforce documentation submission deadlines
• Conduct quality assurance (QA) oversite  
• Utilize key performance indicators (KPIs)

3. Reduce coding errors

One of the most important aspects of accurate revenue capture, ICD-10-CM code assignment determines clinical grouping from the primary diagnosis and patient comorbidity adjustment. The ability to identify co-morbid conditions and associated claims reimbursement is paramount to the success of your revenue cycle.

However, risks arise via non-compliance with official ICD-10 guidelines, inaccurate comorbidity capture and incorrect primary diagnosis. These errors can result in case mix inaccuracies, compliance risk and denials, all of which can severely handicap your revenue cycle.

How to mitigate these risks

• Employ certified coders
• Ensure coder competency
• Gather comprehensive patient medical information
• Establish a compliance diagnosis query process
• Utilize KPIs

4. Close the case management gap

Successful management of patient episodes, visits and outcomes achievement are vital to the overall success of your organization clinically, operationally and financially.

Risks associated with case management include incomplete documentation, inaccurately captured new diagnoses, siloed discipline care and improper use of telehealth visits. These risks can yield disastrous outcomes on your revenue cycle, including increased Low Utilization Payment Adjustment (LUPA) rates, non-compliance and denials.

How to mitigate these risks

• Analyze LUPAs
• Conduct clinician education
• Encourage collaboration and communication
• Manage visits by goals and outcomes rather than discipline
• Implement a clinician scorecard

The Netsmart + McBee webinar goes into these revenue cycle principles in depth. It is free to our readers. Click here to view.

©2021 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Home Care Technology: The Rowan Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com