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As home health providers know, low-utilization payment adjustments can have a detrimental impact to an agency both clinically and financially. If you remember, one of the biggest changes in pdgm is around lupa. Previously, agencies had to have more than 5 views in an episode to avoid the magnifying glass. Pdgm changed the game in loupes and some agencies have not adjusted well. Instead of being a fixed visit threshold, cms changed the focus from the loupe threshold to a sliding scale of visits based on many other factors such as coding, diagnostic grouping, oasis .
Just when we thought we had it under control, CMS has decided to add a whole other level of complexity with PDGM. The challenge to managing LUPA’s under PDGM will be two-fold; a “moving LUPA” for each 30-day payment, and the need to meticulously manage visits within each of those 30-day windows to avoid that LUPA. When COVID-19 surfaced, it prompted patients to turn away visits and encouraged agencies to voluntarily opt to conduct telehealth visits when appropriate. However, virtual visits are not reimbursable and don’t count toward LUPA thresholds.
magnifying glass thresholds
There’s one example that stands out for me; I had a nurse who was scheduled to see a patient on a Friday, but when she got to the patient’s home no one was there. Rather than call me at the office to report the missed visit, the nurse called the doctor’s office and discovered the patient was at a pre-scheduled appointment. If the nurse had called me in the office, we could have rescheduled our visit to the next day and avoided a LUPA. If a RAP is filed for a LUPA, the RAP must be filed timely. With the implementation of Patient-Driven Groupings Model , the Low Utilization Payment Adjustment thresholds changed from four or less visits to a threshold that ranges between two and six visits.
For instance, make your staff aware of what behavioral adjustments are meant to correct. Schedule education sessions that teach the importance of accurate primary diagnoses and appropriate grouping. Invest in coding education or outsource your PDGM home health coding and OASIS assessments.
Low Utilization Payment Adjustment (LUPA)
Under PDGM each of the case mix groups has a threshold to determine if the period of care would receive a LUPA. Payments for 30-day periods with a low number of visits are not case-mix adjusted, but instead paid on a per-visit basis using the national per-visit rates. You can’t miss out on the possibility where the first 30-day care plan with the additional visits might produce better outcomes and the second 30-day period may not be needed and a LUPA can be avoided.
Moreover, this type of impact analysis can help agencies understand what their strengths and weaknesses are moving forward. So, it is important to consider the big picture as you think about your 2020 case-mix strategy. It’s imperative to begin thinking about the management of PDGM visit utilization in 30-day periods of care. For example, for LUPA visits of two or less in a second 30-day period, determine if this low visit count is impacting clinical outcomes. Then consider how moving those one or two visits into the first 30-day period would impact the patient’s outcomes.
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This user-friendly, web-based app enables your agency to quickly and accurately project the financial outcome at the beginning of any/all episodes of care regardless of Payor. And the susceptibility of older citizens to the illness caused many patients to refuse visits from caregivers. This in turn, drove up LUPAs, especially during the early days of the pandemic. COVID-19 threw a wrench into an already complicated LUPA landscape.
Efficient Outcome and Assessment Information Set assessment, effective coding practices, strategic management of the episode and sending in the right discipline at the right time for the correct amount of time is key. Case management remains central, and seamless collaboration and communication has never been more important. Was the episode front-loaded at start of care and resumption of care to potentially reduce the chance for rehospitalization? Front loading is usually at least three visits within the first seven days of care. Now there are hundreds of potential thresholds to manage based on the patients’ diagnosis and condition. Ask HealthPRO how using our Care Pathways to Success will help your agency to avoid LUPAs through care planning based on the clinical characteristics of each patient.
Understanding PDGM What You Need To Know; What …
What was the lupa threshold and how many visits did the agency make? The first 30 day episode had multiple visits and the magnifying glass threshold was easily removed. The second 30 days had a lupa threshold of 2 and the agency made 1 visit and discharged the patient.
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The frequency of low-utilization payment adjustments increased for many home health providers in the first year of the Patient-Driven Groupings Model , which coincided with the COVID-19 crisis. From the findings of your internal LUPA review process, analyze your results and identify whether the LUPA could have been avoided. Investigate trends in avoidable versus unavoidable LUPA cases. In addition to the new LUPA threshold in home health, there are other changes under the new payment model.
Consider integrating additional tools – Homecare Homebase integrates with Medalogix to provide additional utilization guidance based on the unique needs of each patient. Communicate with your patients to avoid potential scheduling conflicts with physician appointments, personal appointments, etc., that could result in a missed visit. Based on the data, LUPAs appeared most likely to occur in the second period under PDGM. Rates also vary highly based on clinical grouping and LUPA threshold. Post-PDGM, there are 432 different LUPA scenarios, with visit thresholds ranging from two to six.
When you talk about LUPA, It is one of the contractual adjustments that currently make up the Medicare-certified home health prospective payment system. However, PDGM provides an introduction towards building a better management team complex structure of visit requirement variables that Medicare home health care providers will need to navigate. King of Prussia, Pennsylvania-based BlackTree Healthcare Consulting provides billing, OASIS and other services to home health agencies, among other post-acute care providers.
For example, for LUPA visits of two or less in the second 30-day period, determine if this low-visit count is impacting clinical outcomes. Then consider how moving those one or two visits into the first 30-day period would impact patient outcomes. LUPAs are just one of the contractual adjustments that currently make up the Medicare-certified home health prospective payment system. Home health agencies have had a five-visit LUPA threshold for some time now with four visits or less per episode resulting in a low-utilization payment adjustment. For your agency to be truly ready for the implementation of this new structure, begin analysis now. It is imperative that prior to this change you understand the impact the new model will have on your LUPAs.
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Some agencies have situations where they believe a magnifying glass cannot be avoided. A common situation in which a loupe can be avoided would be a patient with a foley catheter. Many agencies go once a month to change the catheter and accept a magnifying glass. Can other things be ordered, like sending a home health aide to check on the patient?
Under the Prospective Payment System , there was a single threshold — having to manage five visits over 60 days. Now, there are 432 thresholds to manage based on patient condition — and the time period is cut in half to just 30 days. Sometimes LUPAs can be avoided altogether by retraining agency staff.
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