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CMS is ending the temporary suspension of OASIS data collection on non-Medicare/non-Medicaid HHA patients. HHAs will be required to submit all-payer OASIS data for purposes of the HH Quality Reporting Program beginning with the CY 2027 program year, with two quarters of data required for that program year. We are finalizing a phase-in period for January 1, 2025 through June 30, 2025, in which failure to submit the data will not result in a penalty.
We note that the overall impact of the -3.925% permanent behavioral assumption adjustment is -3.5%, as the permanent adjustment is only made to the 30-day payment rate and not the Low Utilization Payment Adjustment per visit payment rates. The statute requires CMS to determine annually the impact of differences between assumed behavior changes and actual behavior changes on estimated aggregate expenditures, beginning with CY 2020 and ending with CY 2026. CMS must also make temporary and permanent increases or decreases, as needed, to the 30-day payment amount to account for such increases or decreases. In the CY 2022 HH PPS proposed rule, CMS first solicited comments on a repricing methodology to determine the impact of behavior changes on estimated aggregate expenditures. This methodology predicts what the Medicare program would have spent under the pre-PDGM payment methodology, using actual CY 2020 and 2021 data and, thus, accounting for actual behavior changes as a result of the PDGM.
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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 stressing the value of therapy as part of the new payment system.
In other words, CMS ran actual claims under the prior system and compared it to the claims under the PDGM system, which allowed a comparison of aggregate expenditures under both systems in order to determine the estimated aggregate impact of behavior change. 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.
Audiology and Speech-Language Pathology Services
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. Audiology services are excluded from the HH PPS and may be billed independently by the audiologist under the Part B benefit . It contains thousands of paper examples on a wide variety of topics, all donated by helpful students.
The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. CMS requested stakeholder feedback on our work around health equity measure development for the Home Health QRP and the potential future application of health equity in the HHVBP Expanded Model’s scoring and payment methodologies. While the statute also requires CMS to determine one or more temporary adjustments to offset retrospectively for such increases or decreases in estimated aggregate expenditures, CMS has the discretion under the statute to implement these adjustments in a time and manner deemed appropriate. 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.
Home Health Agencies
Ask the patient and/or caregiver if they receive any health care services in their home. To ensure consolidated billing is implemented appropriately, beginning in 2022 home health agencies will need to complete a notice of admission 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 which proved to be an ineffective method for ensuring home health agencies complied with their obligations under consolidated billing. In addition, CMS made additional adjustments to maintain budget neutrality between projections of what would have been spent under the former system and what has been spent under the PDGM.
Therefore, to solve financial and organizational problems arising at different stages, it is proposed to implement PPS. This system has already been able to prove its effectiveness for the activities of healthcare organizations. It has been conducted that PPS positively affects the quality of transplant services. The essence of a prospective payment system is that the amount of insurance compensation is based on a predetermined payment, regardless of the intensity of the rendered service.
MLN Product (Revised): Home Health Prospective Payment System
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. 8581 were to pass, it would provide stability in the industry, strengthen disclosure, accountability, and transparency of the payment rate-setting methodology used by CMS. The proposed 7.85% cuts will have drastic impacts on home health as a whole and will tremendously reduce access to these vital services around the country.
Pressure to accept more patients admitted from institutions (e.g. hospitals) or to accept fewer patients admitted from the community. This is because under PDGM institutional admissions receive a high reimbursement than community admissions. Verify the patient’s benefit through the local MAC’s interactive voice response system or the Medicare Common Working File . A continuing need for occupational therapy can maintain eligibility after one of the initial qualifying services listed above terminates.
Effective October 1, 2000, the home health PPS replaced the IPS for all home health agencies . The PPS proposed rule was published on October 28, 1999, with a 60-day public comment period, and the final rule was published on July 3, 2000. 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.
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. Additionally, this rule finalizes changes to the Home Health Quality Reporting Program requirements; changes to the Expanded Home Health Value-Based Purchasing Model; and summarizes the input received on the health equity request for information for both HH QRP and HHVBP.
Since it is important to consider not only the needs of the organization itself but also of the customers, it is necessary to search for optimal solutions, which can be the introduction of PPS. 8581 prevents CMS from implementing any permanent or temporary adjustment to home health prospective payment rates prior to 2026. This would delay the current proposed cuts and allow more time for CMS to refine its approach to determining budget neutrality in the industry. 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.
However, to mitigate such a large decrease in home health payments in a single year, we are finalizing to phase in the permanent adjustment by reducing it by half for CY 2023. That is, we are finalizing a -3.925% permanent adjustment to the 30-day payment rate in CY 2023 to ensure that aggregate expenditures under the new payment system would be equal to what they would have been under the old payment system. The remaining permanent adjustment, along with any other potential adjustments needed to the base payment rate to account for behavior change based on data analysis, which are all required by law, will be proposed in future rulemaking. This methodology and adjustment are due to the implementation of the Patient-Driven Groupings Model and 30-day unit of payment as required by the Bipartisan Budget Act of 2018, which amended Section 1895 of the Social Security Act. CMS is phasing-in the permanent adjustment by finalizing a -3.925% permanent adjustment for CY 2023. The -3.925% permanent adjustment is half of the full permanent adjustment of -7.85% (-7.69% in the proposed rule).
This payment system aims to provide high-quality services without severe risks to current resources for both clients and medical organizations. Payers have a choice in determining how they pay to ensure that risks are shared fairly. Thus, a situation arises in which the payment system benefits extend to both payers and healthcare service providers.
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 , annual financial limitations on outpatient therapy services). These services could be provided by the home health agency or by a speech-language pathologist in private practice. Home health agencies that provide services—including speech-language pathology services—to Medicare beneficiaries are paid under a prospective payment system 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).
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