While 2020 began with the change to the Patient-Driven Groupings Model (PDGM) for reimbursement taking up home health agencies’ attention, the expansion of Review Choice Demonstration (RCD) was soon to follow. Both of these have been affected by the onset of the Covid-19 pandemic and resulting Public Health Emergency (PHE). At some point the PHE will expire, followed by a resumption of medical review activities by Medicare contractors.
Medicare contractors normally use Targeted Probe and Educate (TPE), Unified Program Integrity Contractor (UPIC), Recovery Audit Contractor (RAC), and Supplemental Medical Review Contractor (SMRC) reviews to evaluate claims for coverage and payment. How the PDGM provides payment will also have a significant impact on review results. This presentation will walk attendees through the PDGM payment model and how it affects medical reviews and denials.
The impact of RCD activity on medical reviews is significant, both for agencies who choose a Pre-Claim Review option or an Additional Development Review (ADR) choice. This presentation will focus on agency actions to lower risks of being chosen for medical review and high-risk areas for denials. The status of the RCD and preparation tasks for when the RCD is started will be addressed. Finally, the PHE changes are also covered with suggestions for compliant documentation during the PHE to prevent problems after the PHE has ended. This program benefits home health agency Administrators/Managers, Clinical Supervisors/Managers, Directors of Nursing, and QA/QI staff.
This presentation attendees will take back to their agency:
- Understanding of the PDGM payment model and their relation to claim denials;
- Documentation needs within the PDGM payment model to lower chance of causing a review or
denials in case of review;
- Reminders on best compliance within the RCD; and,
- PHE waivers to care and how to best implement them during the PHE and transition after the PHE
Meet the Speaker
Joe Osentoski, BAS, RN-BC, is the ADR and Appeals Specialist for Gateway Home Health & Consulting. He has over 25 years in home health and hospice specializing in clinical quality assurance and regulatory compliance. He has extensive experience with all types of medical reviews from all Medicare contractors and has handled thousands of appeals. Joe has been lauded by retired U.S. Administrative Law Judge Robert Soltis in his book, How to Handle Your Medicare Hearing: “...His credibility is beyond reproach.” He is also the author of Home Health ADRs and Appeals Answers, First Edition, published by Decision Health.
Attendees receive 1.0 continuing education units for skilled nursing, occupational therapy, and speech therapy.
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- Prospective Members: $58
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