Despite Dire Predictions, Agencies Can Thrive Under PDGM


The Patient-Driven Groupings Model is certainly the biggest change to Medicare home health reimbursement in 20 years. However, this fundamental challenge to revenue cycle management is less daunting for providers who use Axxess solutions. During the recent Home Health Care News Summit in Chicago, industry leaders painted a dark view of PDGM’s potential impact, with some using the word “carnage” to describe the expected result for many provider agencies. Axxess has a much different view for our clients. We view this an opportunity for providers to thrive in 2020 and beyond.

Lessons Learned

Veterans in the home health industry recall the closures of thousands of failed agencies when the last Medicare payment reform was implemented 20 years ago. That was when the Centers for Medicare and Medicaid Services (CMS) moved the industry to the current Prospective Payment Systems (PPS) model.

Twenty years is a long time, and for those agencies and employees who survived the transition to PPS those memories can seem haunting. But that was a different time. Many in the industry have learned from those lessons to prevent it from happening again. This time around the experts, the resources and the national leadership are all in alignment to stand united.

Axxess is Prepared for PDGM

This is why I believe industry “carnage” is unlikely when PDGM begins on January 1. Axxess has been proactive in preparing for this transition and we’ve empowered our clients and the industry with resources and solutions to get ready. Our team of in-house engineers have developed features in Axxess AgencyCore that will help grow business and mitigate any risks that come during the transition to PDGM.

Some of the main threats to revenue under PDGM are directly addressed by our features:

  • Questionable Encounter Codes Alerts
    • We have alerts that warn staff during intake if a code will not be payable under PDGM. The system does not allow the code to be used and prompts staff to collect enough information to determine the proper code.
  • PDGM Modeling Tool
    • Right at intake, our tool gives clients an estimate of the reimbursement under PDGM for each patient. This can also help train staff on how factors on the claim and the OASIS assessment come together to generate a payment.
  • LUPA Avoidance
    • Our Case-Mix Analysis makes it clear up front what the LUPA threshold is for each billing period in the episode. That will make it easier to avoid front-loading visits and then losing out on payment for both billing periods (remember, there will be two 30-day billing periods in a 60-day episode).

Axxess has added workflow and billing automation to ensure our clients can submit claims quickly and get reimbursed faster. We also have orders and documentation management integrations that streamline processes so our clients can manage orders seamlessly and efficiently.

There is a concerted effort between industry associations, consultants, and technology partners like Axxess to support providers through this change to a new reimbursement model. The collaborative strategy includes public policy and legislative advocacy; Medicare home health data analysis and forecasting; PDGM-ready software solutions; and clinical coding and compliance education that will all help the industry succeed.

Innovation and Education Will Get You PDGM Ready

Axxess is hosting training workshops nationwide to educate providers about the things they can do to prepare for PDGM. Each seminar features expert advice with practical strategies that can be implemented immediately.

No matter how much education, planning or analysis an agency has completed this year, if the agency’s scheduling, coding and billing platform is not fully PDGM compliant, that agency is vulnerable to serious financial challenges. That is why the most critical thing for providers after January 1 will be the software solution used in the agency office, and on the laptops and mobile devices in the field. Axxess clients are already ahead of the curve because of the innovation in our solutions and are positioned to thrive under PDGM.