During the COVID-19 pandemic and following the implementation of the Patient-Driven Groupings Model (PDGM), home health agencies faced considerable challenges managing Low-Utilization Payment Adjustments (LUPAs). Although some successfully adopted strategies to reduce LUPAs, many agencies continue to struggle.

Current LUPA Landscape

According to data from the National Association for Home Care & Hospice (NAHC), LUPA rates were causing a decrease in average reimbursement by approximately 75% for home health agencies during the height of the COVID-19 pandemic, which added strain to an already challenging situation.

In 2020, nearly two-thirds of agencies reported that LUPAs had at least doubled, as revealed by NAHC data. This indicated the widespread struggle that agencies faced in managing LUPAs effectively.

Based on CMS data up to Q3 of 2022 and further analysis by McBee Associates, the national average LUPA rate stood at approximately 7.6%. When breaking down the data, LUPA rates were found to be around 9.79% for the first 30-day period and 6.54% for subsequent periods.  These findings highlighted the variation in LUPA rates between different timeframes and the need for agencies to consider such variations for accurate assessment and monitoring.

Home health agencies were advised not to solely rely on the overall LUPA average when analyzing their performance. Instead, the LUPA rates within the first 30 days should be assessed separately from the rates in later periods. By doing so, agencies could identify any inconsistencies and ensure they were on target with their LUPA management strategies.

Interestingly, a closer look at the Q3 2022 data revealed that the majority of subsequent period LUPAs, almost 84%, were only a single visit short of meeting the LUPA threshold. This finding indicated that making simple adjustments during the second 30-day period could significantly benefit agencies still grappling with LUPAs.

Overall, the struggle to minimize LUPAs has persisted for many home health agencies, even as some agencies implemented effective strategies. The financial impact of increased LUPA rates, the national average LUPA rate, and the variation between different timeframes underscored the ongoing challenges faced by home health agencies in managing LUPAs.

How to Mitigate LUPAs

Streamlining OASIS Documentation

Some home health agencies have successfully adjusted to the changes brought about by PDGM, while others are still facing difficulties. The crucial factor lies in having efficient internal processes for timely coding and OASIS documentation.

Under PDGM, the LUPA thresholds can vary for each patient over a 30-day period, making it important for agencies to closely monitor different LUPA thresholds and visit intensities for each patient. This can be effectively done when the OASIS is completed early on in the payment period.

Once the OASIS is complete, the case-specific LUPA threshold can be identified as well through the home health resource group (HHRG) and Health Insurance Prospective Payment System (HIPPS) code. With the LUPA threshold being identified early on in the payment period, home health agencies can properly plot visit schedules, and anticipate and address missed or canceled visits, thus avoiding LUPAs.

However, accomplishing this task is challenging, as various factors influence the timeliness of OASIS completion. These factors include the promptness of clinicians in submitting their OASIS and the turnaround time for the coding and QA review. Without streamlined processes, this can take up to 10 days or more, or about one-third of the payment period.

Staff Education

Home health agencies should prioritize educating their staff on best practices to prevent LUPAs. It is crucial to ensure that all staff members, including those involved in scheduling 30-day billing periods, are well-informed of the implications of moving visits and the importance of tracking their progress within the billing periods. Additionally, a thorough understanding of LUPA thresholds is essential for everyone involved to effectively manage and minimize LUPAs.

Paying Attention to Patients’ Needs

To prevent overwhelming the patient, it is advised to avoid scheduling too many visits within the first 30 days, including nursing, physical therapy, occupational therapy, and social work. Providing an excessive number of visits can lead to patient refusal and potentially contribute to LUPAs. Instead, spreading the care throughout the 60-day episode, both in the first and second 30-day periods, allows for better patient service and helps mitigate the risk of LUPAs.

Reinforcing Clinical Operations for LUPA Prevention

The added complexities in the new OASIS-E pose an increased challenge in completing OASIS documentation promptly. Clinicians will need additional administrative help and efficient solutions to help expedite OASIS documentation without compromising accuracy. Seeking expert support can play a significant role in alleviating this burden. This approach will allow for early identification of LUPA thresholds within each payment period, empowering agencies to strategically plan visit schedules and proactively address any missed or canceled visits. With third-party support to reinforce clinical operations, agencies can effectively avoid LUPAs and optimize reimbursement while maintaining a high standard of care for their patients.

The post How to Address the Ongoing LUPA Challenges first appeared on Qavalo.

When OASIS submission, coding, and QA review were streamlined, Qavalo’s client agencies saw significant improvements in their OASIS turnaround time and realized better compliance and profitability.

With the right outsourcing partner, Qavalo clients have been able to get the support their in-house teams need to find efficiencies in their documentation workflow and seize big picture process improvement opportunities.

Benefits Realized

• Consistent OASIS submission-to-completion process
• Faster OASIS submission time
• Shorter OASIS turnaround time
• Declining LUPA rates
• Optimized reimbursement values

PDGM Turnaround Time Challenges

The Patient-Driven Groupings Model (PDGM) overhauled the entire home health reimbursement system with new case-mix weight calculations, new LUPA thresholds, new Request for Anticipated Payment (RAP) requirements, and shorter payment periods, among other big changes.

Request for Anticipated Payment (RAP)
In 2020, CMS introduced RAP, requiring agencies to submit initial documentation to authorize care under a home health agency and establish the care episode. Though a complete OASIS is no longer a requirement to file a No-Pay RAP this year, it is still best for agencies to complete the OASIS within the 5-day window period.

HHRG and HIPPS codes
Based on an OASIS assessment, 30-day periods under PDGM are classified under a variety of patient information and other clinical characteristics, such as admission source, timing, clinical grouping, functional impairment, and comorbidity. This results in a Home Health Resource Group (HHRG) combination for which CMS will generate a PDGM case-mix weight represented as a Health Insurance Prospective Payment System (HIPPS) code on Medicare claims.

Completion of the OASIS in time for RAP filing allows agencies to determine the claim’s HHRG classification and a HIPPS code that is more reflective of the actual patient case. This is important so that the assigned HIPPS code in the RAP would be more consistent with the HIPPS code in the final claim, thus lowering the chance of the agency being flagged for an Additional Development Request (ADR).

Low Utilization Payment Adjustments (LUPA)
With PDGM, LUPA thresholds vary per HHRG over a 30-day period, which means agencies should closely monitor different LUPA thresholds and visit intensities for each patient. Early identification of the LUPA threshold though the HHRG and HIPPS code will help agencies plot and schedule visits accordingly to prevent claims falling under LUPA.

These changes underscore the need for home health agencies to fast-track their process, improve documentation turnaround, and observe strict OASIS completion timelines in order to address key functions that affect claims approvals and reimbursement values. This is no easy task since an OASIS needs to undergo a number of processes, including coding and QA review, before being completed. In many cases, this can take up to 10 days—or ⅓ of the care period—if processes are not streamlined.

Qavalo Solutions in Numbers

To address the abovementioned challenges, Qavalo applies several workarounds and best practices to help agencies achieve the ideal workflow and succeed in timely submissions. 

• Timely coding and OASIS review to allow agencies to identify LUPA thresholds ahead of time, and generate a HIPPS code that is reflective of the actual patient case.
• Coding is done as soon as the OASIS is available in the QA manager.
• Coders are available seven (7) days a week.
• OASIS QA review is completed within 48 hours after coding.
• There is efficient resolution of escalations of OASIS quality issues.
• Qavalo proactively notifies agencies of trends on late submissions of OASIS by the clinicians.

Figure 1.1 shows the average OASIS submission time of clinicians across all home health agency clients of Qavalo. In January 2021, average OASIS submission was at 2.52 days, and by May 2021, this decreased to only 1.41 days.

More importantly, figure 1.2 below shows the average OASIS turnaround time from clinician submission to final approval. From January to May of 2021, Qavalo home health agency clients were able to realize completion of the OASIS within an average of 3.16 days.

Though a complete OASIS is not required to submit No-Pay RAPs since January 2021, clinicians were able to maintain early submission of OASIS, allowing other OASIS processes,  such as coding and QA review, to be accomplished in a timely manner. In addition, Qavalo’s QA review program supports clinician reeducation, helping them improve their charting skills overtime. This resulted in an efficient end-to-end average OASIS turnaround time of 3.16 days, which falls within the 5-day RAP filing window.

Due to efficiencies in the OASIS completion timeline, LUPA thresholds were identified early on in the payment period, allowing agencies to properly plot visit schedules, and anticipate and address missed or cancelled visits, thus avoiding LUPAs.

Figure 2 below shows sample data from one of Qavalo’s clients, Palmeria Home Health in Arizona and Nevada. The graph shows the percentage of Palmeira’s LUPA episodes from the fourth quarter of 2020 to the second quarter of 2021.

In Q4 of 2020, only 7% of all episodes fell under LUPA. Even with the implementation of No-Pay RAPs in 2021, when the OASIS is no longer required to be completed within 5 days, LUPA rates continued to drop at 6% by Q1 and down to only 4% by Q2.

While early identification of LUPA thresholds greatly helped agencies, LUPAs were not completely avoided because of some uncontrollable factors such as cancelled visits due to patients’ anxiety towards COVID-19.

The Right Partner for the Job 

Based on data, Qavalo’s home health agency clients realized a better OASIS turnaround time. Beyond the scope of documentation review and coding, Qavalo maintains ongoing collaboration with in-house teams and leverages data to help agencies have a comprehensive view of their documentation workflow and properly address gaps. This path of progress will only lead to more streamlined processes, resulting in better patient outcomes and business profitability.

The post PDGM Challenges: Optimizing Profitability Through Efficient OASIS Turnaround first appeared on Qavalo.

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.

Resources:

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

The post Real LUPA Scenarios: Finding What Works first appeared on Qavalo.