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Real LUPA Scenarios: Finding What Works

    LUPA and the Pandemic

    In the first few months of the Patient-Driven Groupings Model (PDGM), the frequency of low-utilization payment adjustments (LUPAs) increased for many home health providers to 9.5% according to a home health news source. While this aligns with the projection from the Centers for Medicare & Medicaid Services (CMS) that about 10% of all claims were LUPAs, the LUPA rate continued to increase to about 25% with the onset of the COVID-19 pandemic.

    In early 2020, the National Association for Home Care & Hospice (NAHC) released survey results that suggested more than 67% of all home health agencies have seen their LUPA rates at least double as a result of COVID-19. As such, home health agencies in areas hit worst by the coronavirus generally have seen the highest LUPA rates.

    There are many factors that caused the increase, including sudden hospitalizations due to unplanned complications, staffing shortages tied to quarantine protocols, and canceled visits because of both clinicians and patients’ fears and anxieties. For instance, even making up for a missed visit immediately the next day could still lead to a LUPA in the new 30-day period. Additionally, access to patients in facilities was also a challenge in 2020, which made the scheduling process more difficult. Visitation cancellations also encouraged agencies to conduct telehealth visits when appropriate instead. However, virtual visits are not reimbursable and do not count toward LUPA thresholds.


    Operational Challenges

    One of the unintended consequences of the No-Pay RAP in 2021 is that OASIS does not have to be completed upon submission of the RAP, which results in agencies having a blind spot for LUPA. In many cases, agencies submit a No-Pay RAP but do not know what the LUPA threshold is when developing the Plan of Care (POC or 485). Previously, OASIS had to be completed, which meant that agencies would know the diagnosis group, HIPPS code, and ultimately the LUPA threshold before the RAP could be submitted. Identifying the LUPA threshold ahead of time would have allowed agencies to properly plan out visits right upfront.

    In the real scenario, many agencies are often already 1/3 into the care period before identifying the LUPA threshold. Before the OASIS is completed and a HIPPS code is determined, QA review takes place wherein clinicians are sent feedback and make necessary changes in the OASIS. All of this is potentially 10 days into the period, and that HIPPS code is going to determine what that LUPA threshold is. Finding efficiencies in the QA review and OASIS completion timeline can significantly help fast-track the process.


    Finding Solutions

    Aside from maintaining top-down continuity of LUPA knowledge from agency leaders to field clinicians, working with an efficient OASIS documentation provider can help keep agencies’ heads above water.

    Your QA provider must be able to perform timely coding and OASIS review to allow you to identify LUPA thresholds ahead of time, and generate a HIPPS code that is reflective of the actual patient case. This means that:

    1. Coding must be done as soon as the OASIS is available in the QA manager.
    2. OASIS QA review must be completed within 48 hours after coding.
    3. Your provider must proactively notify you of trends on late submissions of OASIS by the clinicians.
    4. Your provider should also be able to help you check and monitor if the order of visits plotted in the episode manager meets LUPA thresholds.

    While knowledge is power, working with a provider that can look at things from a bird’s eye view and understand the bigger picture can give you peace of mind. LUPA prevention requires timing that has to be executed perfectly. All parties involved need to be in sync to succeed and LUPA management will continue to require diligence from agencies and providers alike.



    HHHCN| Home Health LUPA Challenges Continue as Pandemic Subsides
    HHCN | By the Numbers: Breaking Down Home Health LUPA Patterns