Innovation That Solves the PDGM Staffing Puzzle


Home health providers are starting to absorb the massive impact that the new Patient-Driven Groupings Model (PDGM) will have on the industry, and realizing what this new reality will look like when the model goes into effect January 1, 2020. The staffing challenge in the home healthcare industry remains a critical concern, and the stress of recruiting and retaining employees could be made worse while trying to decipher the new regulations. Axxess is providing help with a PDGM resource page featuring content that explains the change. Successfully navigating PDGM is possible when using the right tools; providers may even be able to grow their business using AxxessCARE.

Avoiding a LUPA

Under PDGM, Low Utilization Payment Adjustment (LUPA) thresholds fluctuate based on the Home Health Resource Grouping (HHRG) and the split billing periods. The new threshold is between two to six visits in a 30-day billing period. This makes it even more important not to have a missed visit because, depending on the timing and the diagnosis, the provider could end up with a LUPA in both the first 30 days and the second 30 days. In a recent webinar, Axxess outlined the new PDGM episode payment model.

Below is an example of LUPA reimbursement and revenue loss for a 30-day billing period. Let's assume the diagnosis would require five visits to avoid becoming a LUPA. A provider that is only able to complete four visits would receive a reimbursement of $586 under the 2019 CMS LUPA rates, which represents a total revenue loss of $1,167.68

The amount of revenue lost because of the LUPA is substantial, but it is avoidable when using AxxessCARE, Axxess' robust scheduling and staffing solution. The platform connects home health agencies with clinicians to provide timely care.

Using AxxessCARE, an agency sets the rates for each visit, and under the right circumstances this solution can help the agency avoid a LUPA. Using the same scenario used above, the diagram below shows how posting a visit on AxxessCARE at a rate of $50 can avoid a LUPA for the billing period, which brings in hundreds of more dollars to the bottom line.

Therapy Utilization

Another major change that is coming with PDGM is the elimination of additional reimbursement for therapy visits. It is important to know your organization's therapy utilization rate to determine risk for decreased reimbursement. If that number is above the national average, then it is time to start looking at more cost-effective ways to deliver rehabilitation solutions. CMS will still require rehab outcomes to be maintained, but there will no longer be additional reimbursement for this service. AxxessCARE can be used for scheduling physical therapy visits and is an excellent way for providers to reduce the need for full-time equivalency (FTE) employees.

AxxessCARE is available to Axxess clients. Visits posted through AxxessCARE can be done one at a time or in bulk. Prior to connecting with interested agencies, nurses and physical therapists who use AxxessCARE undergo background checks, license verifications, and are run through the Department of Health and Human Services' Office of the Inspector General (OIG) database.

Clinicians doing visits using AxxessCARE are rated using a star system that makes it easy to spot a quality applicant and select the best person for the patient. The process is enjoyable for both the agencies and the clinicians who use the platform.

Adjusting to the new reality of PDGM can be easy if you are willing to embrace innovative solutions like AxxessCARE. The important shift in the home health reimbursement model was set up during the Bipartisan Budget Act of 2018. The only way PDGM would be delayed is, quite literally, by an act of Congress. The time to prepare for this change is now. Start by getting familiar with and using AxxessCARE.