Your home healthcare clients with specific diagnoses may become Medicare beneficiaries at a younger age than 65. If you have a client with Multiple Sclerosis (MS) or another neurodegenerative disorder, the Social Security Administration’s approval for receipt of Social Security disability benefits (for at least 24 months) may signal that this client is eligible for Medicare coverage regardless of age. Likewise, clients with autoimmune disorders resulting in permanent disability status may also be Medicare-eligible before 65 years of age. In turn, that change in insurance coverage can have a major impact on your home health billing and revenue.

As a home healthcare (or hospice) agency executive or administrator, planning for the transition to Medicare’s Patient-Driven Groupings Model (PDGM) in 2020 includes anticipating the percentage of your clients that will require the submission of Medicare claims. The following describes the potential home healthcare needs of homebound clients diagnosed with MS or a severe autoimmune disorder, as well as the statistics related to home healthcare use by permanently-disabled adults with neurodegenerative or autoimmune disorders.

Furthermore, utilizing the services of Liberty Consulting and Management Services in Illinois can assist you in preparing for Medicare’s roll-out of the PDGM.

Multiple Sclerosis (MS) and Medicare

An American Journal of Managed Care article in 2016 reported that 53.9 percent of people diagnosed with MS in the US had privately-administered health insurance. However, between 25-30 percent of all people diagnosed with MS are covered by Medicare (per the National Multiple Sclerosis Society). Meanwhile, a report of the Illinois Department of Public Health estimated that 20,000 people in Illinois were living with MS as of 2015. This report concluded that at least two geographic areas in Illinois had a higher-than-average incidence of MS.

In addition to episodic blindness, homebound (and wheelchair-bound) adults with severe MS all too often experience the following co-disorders:

  • Incontinence (necessitating periodic or ongoing catheterization);
  • Joint injuries due to “slip and fall” accidents;
  • Decubitus ulcers (bedsores);
  • Depression and/or anxiety

On January 1, 2018 – as described on the website of the American  Speech-Language-Hearing Association (ASLHA) – the annual outpatient rehab services cap of $2,010 was repealed, and a requirement enacted for a targeted medical review after an expenditure of $3,000. Therefore, your Medicare-covered clients with MS may have sought additional home-based rehab services (e.g., physical, occupational, or speech therapy).

Notably, an article on the website of Home Care Association of Florida suggests that home healthcare agencies providing a high annual proportion of total therapy to nursing visits may incur financial penalization under the PDGM.

Overall, it is vital to recognize that – as of 2020 – the adjusted case-mix (totaling 432 different case mix groups) under Medicare’s impending PDGM will change the level of home healthcare agency reimbursement. According to a presentation in 2019 of the Centers for Medicare and Medicaid Services (CMS), the PDGM payment system will create 153 Home Health Resource Groups (HHRGs) based on clinical, functional, and service utilization severity levels. Therefore, it is essential for your clinical staff to have a clear understanding of your MS clients’ limitations in terms of essential Activities of Daily Living (ADLs) and any complications and/or co-disorders.

Amyotrophic Lateral Sclerosis (ALS)

The ALS Association reports that 5,600 people annually in the US are diagnosed with ALS. Difficulty speaking and swallowing are frequently experienced by adults with advanced Amyotrophic Lateral Sclerosis (ALS) – commonly-called Lou Gehrig’s Disease. On January 1, 2018, a provision of the Steve Gleason Act was legislatively-enacted. This has enabled Medicare coverage for the purchase of SGDs (customized electronic augmentative and alternative communication devices), as described in CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 4027.

Similar to predicting home healthcare agency payment under the PDGM for services to MS clients, it is crucial for your clinical staff to understand the limitations and co-disorders of your clients with ALS (and other neurodegenerative disorders).

What Rheumatoid Arthritis (RA) and Crohn’s Disease Have in Common

Rheumatoid arthritis (RA) differs from osteoarthritis in that it is an autoimmune disorder (resulting in an immune system attack on the joints, creating joint lining inflammation). Crohn’s disease is an inflammatory bowel disorder that is also caused by an autoimmune response. According to the Crohn’s and Colitis Foundation, 25 percent of people with Crohn’s disease experience a co-disorder of inflammatory arthritis.

Under the PDGM, 24 co-morbid conditions are allowed, with 11 co-morbidity subgroups qualifying the home healthcare provider for a payment adjustment (specified as low or high). This will necessitate changed calculations by home health (or hospice) agency accounting personnel to incorporate the assignment of a low or high severity score for the given co-morbid condition.

According to an article in Home Health Care News in 2019, a high co-morbidity adjustment will incur a higher projected payment to a home healthcare agency for the 30-day payment period (thereby suggesting that acquiring new Medicare clients with more severe co-morbidities may result in higher Medicare-based revenues than acquiring clients with fewer severe co-morbidities).

Lupus and Co-Morbid Conditions

The Lupus Foundation of America reports that 1.5 million people in the US are living with Lupus (Systemic Lupus Erythematosus [SLE]), which is an autoimmune disorder that can affect nearly every organ. This nonprofit also notes that one in every three Lupus-afflicted persons suffers from other autoimmune disorders. Lupus is also one of the chief causes of permanent kidney failure (ESRD) necessitating dialysis or a kidney transplant. Medicare coverage for ESRD-afflicted persons is available at any age (per the CMS booklet in 2018, Medicare Coverage of Kidney Dialysis and Kidney Transplant Services).

Anticipating annual Medicare payments is crucial to predicting your revenue stream. Recognizing the proportion of your clients that are Medicare-insured is likewise important, so that your home health accounting staff can more accurately predict cash-flow. Meanwhile, your clinical staff can enable improved predictive insurance classification of clients by the home health accounting staff through rapid reporting of diagnosed ESRD in your Lupus-afflicted clients.

PDGM and Request for Anticipated Payment (RAP)

The OASIS pertaining to a client does not need to be submitted under the PDGM prior to the Request for Anticipated Payment (RAP) (per an article in HomeCare in 2019). However, as before, the percentage payment for the RAP will be based on the HIPPS rate code.

In 2020, the change under the PDGM from a 60-day episode of care to a 30-day payment period translates into increased RAPs for existent home healthcare agencies. Indeed, home health billing and home health accounting are likely to become more complex under the PDGM. Therefore, embarking on a near-term plan of re-education for any staff involved in home health billing and home health accounting is critical in order to not receive an increased proportion of Medicare claim payment denials.

An excellent first-step to transitioning your home health billing and home health accounting operations to optimal functioning under Medicare’s PDGM is to contact Illinois’ Liberty Consulting and Management Services.