by Tim Rowan, Editor
NAHC staff email addresses are standardized at [three initials]@nahc.org. So, President Bill Dombi's middle initial, A, is well known by anyone who has his email address. What the A stands for, less so. If it is not "advocacy," however, perhaps it should be.
The NAHC president has been sought out by nearly every national publication since the pandemic was declared. With or without a reporter on staff who is familiar with our industry, they want to know how the crisis is affecting home health. This week, on the evening between two all-day PDGM webinars, with dinner waiting for him, he took a few minutes to bring us up to date on his efforts to educate CMS about what we need to survive this challenge.
"We just published the results of our survey of Medicare home health agencies," he began, "in which we heard from 1,119 home health companies from all states. We wanted to be able to take some concrete data with us when we talk to CMS." Those talks have been constant lately. The novel corona virus hit the U.S. at the same time PDGM did and the dual impact has been greater than the sum of its parts.
"Large, national agencies tell us they are recording 10%, 20%, even 30% census reductions. With elective surgeries canceled, home health companies are seeing almost no joint replacement cases. On the other hand, you would think that accelerated discharges from hospitals and skilled nursing facilities, plus the people who are afraid to enter a SNF and elect in-home care instead, would benefit home health. But many of those patients are afraid to allow anyone in their homes, for fear of being infected."
This fear contributes to one of the NAHC survey's findings, doubling and tripling of LUPA cases. "LUPA rates reduce average reimbursement by approximately 75% or $1500 over a 30-day period," Dombi reminded us. Agencies that were below national averages are the ones that have seen their LUPAs triple.
NAHC advocacy efforts are focused on an area where the pandemic and the new home health billing system cross paths. "The rules say you must bill in 30-day cycles," Dombi explained, "and that you must have all orders and care plans signed by the referring physician before you can submit a claim. This has often required sending a person to sit in a doctor's waiting room until he or she signs and hands over the paper documents. Today, our members are telling us, especially in the hard-hit states in the northeast, 'you can't find a doctor, no matter how long you wait in a waiting room.'"
Add to this the reduction of RAPs to 20 percent of the anticipated episode payment, Dombi added, and cash flow under PDGM became an issue even before the virus arrived on our shores. "We suggested that it makes sense to allow other medical professionals in a physician practice to sign orders," Dombi continued. "Physician Assistants and Nurse Practitioners work under a doctor's supervision anyway. We are not asking that they issue orders or approve care plans, just that they take some of the paperwork burden off the doctor and sign home health orders. CMS says it would lead to home health patients being under the supervision of a lower licensed professional, but that's not what we are asking for."
Emergency payments under the special programs initiated to help Medicare providers cope with these extraordinary times are helpful, Dombi told us, and many home health providers have applied for the Accelerated Payment Program. What would help even more than loans, he has been insisting to government regulators, would be to pay the full episode amount.
With the PDGM rules came a further rate reduction that CMS said was necessary to balance out games and tricks providers would deploy in order to recoup some of the losses from PDGM's lower reimbursement rate schedule. The so-called "behavioral adjustment" is a preemptive cut based on behaviors CMS assumed providers would make. NAHC and others were able to convince regulators in time for the final rule that, even if their assumptions were accurate, there would be no way for home health agencies to make all assumed operational changes on day one. They managed to get the behavioral adjustment cut reduced from 8.01 percent to 4.36 percent of the episodic payment.
Getting CMS to eliminate the 4.36 percent cut for the duration of the pandemic has been an uphill battle. Asked about the progress of that effort, Dombi said, "They haven't said 'no' yet. We keep asking them and they keep saying 'we're considering it; we'll let you know.' 4.36 percent may not seem like a lot but restoring it would be a big help to the agencies in the hardest hit areas."
The obvious solution to the problem of elderly patients afraid to go into a SNF and afraid to allow a home health nurse into their homes is to check in on them remotely. Currently, Medicare reimburses physicians for conducting remote visits but not home health nurses. This even though the physician video visit is occasional where the remote home health check-ins could be daily, providing better care than in-person visits alone.
"CMS says they do not trust us to use this technology honestly either," Dombi reported, quoting an official directly. "'If we count a remote visit the same as an in-person visit, what's to stop an agency from using it to add a visit to an episode that otherwise would have ended in a LUPA? We're not going to pay them $1,500 for one telehealth visit.' They are conditioned to assuming the worst-case scenario and applying it to every episode. They can't force themselves to consider the benefit of dropping in on a patient remotely many times per week in addition to once in person."
Nevertheless, he keeps trying. Whatever his middle name is, he promised to keep us informed of his progress.
©2020 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