For the first time since 1998, Congress has significantly revised the Home Health (HH) payment model. The Bipartisan Budget Act (BiBA) of 2018, with its subsequent rulemaking and feedback process, went into effect on January 1, 2020 and is called the Patient-Driven Groupings Model (PDGM). Congress mandated Medicare to create a Home Health (HH) payment reform model to be budget neutral in transition, to have stakeholder involvement, to transition to a 30-day payment unit, and very remarkably to prohibit therapy volume thresholds. One could argue that the former HH payment model was very driven by therapy visits, while in contrast, PDGM is driven by:

  • Admission Source & Timing: whether the referral is from an Institutional (ACH, LTACH, IRF, SNF) or Community (PGP) provider, and whether the beneficiary received Institutional care within 14-days prior to the HH admission date;
  • The Clinical Grouping (from the principal diagnosis on the HH claim) the beneficiary will be coded under;
  • The Functional Impairment Level (from the OASIS) of the beneficiary; and the
  • Comorbidity Adjustment (from the secondary diagnoses on the HH claim).

To maximize the integrity and success of our HH Performance Networks, Fusion5 has developed internal analysis and strategies for PDGM.

Very notably, Bill Dombi, President of the National Association of Home Care & Hospice (NAHC), the nation’s largest HH advocacy/association, joined Shawn Matheson, VP Provider Solutions, to discuss key elements of PDGM and how we should proceed.

Please click the webinar link below to view this important information, and if you haven’t already please reply to your Fusion5 Regional Team to discuss specific strategies.  Please also see our prior webinar and handouts on the SNF PDPM payment model.

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