Senate Introduces New Legislation to Vastly Improve PDGM

Posted on Saturday, February 16, 2019 2:42 PM

Bipartisan legislation has been introduced in the United States Senate to improve home health payment reforms to ensure beneficiary access to quality care services is not compromised for America’s growing senior population.  This new legislation will ensure that home health payments and behavioral-based adjustments are based on evidence and collected data. 

The Patient Driven Groupings Model is the most significant change in payments for the home health system in 20 years.  “As part of the Bipartisan Budget Act of 2018 (BBA), Congress called for any changes in the home health prospective payment system (PPS) to be budget neutral, so that any changes would result in the same federal outlay as is currently projected to occur with the current PPS. To achieve this, CMS was authorized to adjust reimbursement rates utilizing assumptions of how provider behavior might change in a new payment model. The assumptions listed included up-coding, documentation of additional diagnosis codes, and a decrease in low-utilization payment adjustments with a corresponding increase in full episodic claims.”

As you know, if implemented as is, PDGM will make payments based on behavioral assumptions instead of actual billed services.  The estimated effect of this new payment structure is a reduction in payments of 6.42%, which equates to one billion less. 

This proposed legislation would require Medicare to implement adjustments to reimbursement rates only after occurring instead of basing it on assumptions.  This would require the payment model to utilize observed evidence of behavioral changes, the bill would ensure a smoother transition to the new payment system. The bill also provides a phase-in of payment changes, limiting losses or gains to two percent per year, while still ensuring budget neutrality is maintained. The bill also includes important provisions that allow for the “homebound” requirement that limits Medicare beneficiaries’ eligibility to receive home healthcare services to be waived in certain instances.

NAHC fully supports this legislation and asks for you to contact your Congressional Representatives to ask them to support it fully. 

Source: NAHC Report

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