Author: Harper Dion
Posted Date: June 20, 2023
Throughout its existence in the healthcare system, the world of post-acute care has experienced uncertainty. During this period, CMS implemented countless operational changes, both big and small, that have caused disruptions to documentation processes and regulation. Regulatory changes are an inevitable aspect of the healthcare industry, and they bring significant impact on revenue cycle management (RCM), especially for smaller home health agencies. With updates to laws, regulations, and policies, home health RCM processes become increasingly complex, requiring constant adaptation to comply with new requirements. The stakes are high for agencies that fail to stay informed and adjust their RCM strategies accordingly. The impact of regulatory changes on RCM can plunge agencies into uncertainty as the very nature of this essential sector is subject to change at any time.
Regulatory changes affecting home health RCM
There have been several regulatory changes affecting home health agencies in recent years, particularly in terms of reimbursement rates, documentation requirements, and quality reporting.
Reimbursement rates for home health services have been updated under the Patient-Driven Groupings Model (PDGM) which was implemented in 2020. PDGM is a payment model that uses patient characteristics to determine payment amounts for home health services.1 This model replaced the Home Health Prospective Payment System (HHPPS), which determined agency pay based on the number of patient visits. PDGM requires home health agencies to provide more detailed documentation regarding patient issues to determine payment rates. As a result, agencies may experience changes in their revenue depending on their ability to document these factors appropriately.
In terms of documentation requirements, home health agencies must comply with the Conditions of Participation (CoPs) set by CMS. The CoPs outline the requirements for patient care, staffing, and documentation to ensure that services are provided in a safe and effective manner.2 Agencies must maintain accurate and complete records of patient care, including documentation of assessments, care plans, and progress notes. Failure to comply with CoPs will result in reduced reimbursement rates, and in extreme cases, loss of certification as a Medicare provider.
Quality reporting has also become a significant factor in deciding reimbursement rates. The Home Health Quality Reporting Program (HHQRP) requires agencies to document a variety of quality measures related to patient care, like medication management and patient experience.3 Agencies that fail to report these measures accurately are subject to reductions in their reimbursement rates. Furthermore, the Quality of Patient Care Star Ratings, which are based on HHQRP data,3 is publicly reported on the CMS Home Health Compare website4 and holds influence over patient decisions of home health providers.
If unprepared, these regulatory changes can significantly affect the revenue and overall financial success of a home health agency. Accurate documentation and timely reporting are essential for maintaining reimbursement rates and achieving positive patient outcomes. Failure to comply with these requirements will result in reduced revenue, and as mentioned in some cases, loss of certification. As a result, it is crucial for home health agencies to stay up-to-date on regulatory changes and invest in effective systems to ensure financial stability and long-term success.
Implications for home health agencies
Regulatory changes in home health increase administrative burden for agencies. The already understaffed entity must devote more time and resources to ensure accurate documentation, timely reporting of quality measures, and compliance. Non-compliance with these changes leads to penalties, and significantly decreased patient and caregiver satisfaction.
To maintain compliance, home health agencies should consider investment in technology and training, focus on staff education and collaboration, and partner with other healthcare providers. Technology can help manage the administrative burden associated with documentation and reporting. Staff education and collaboration are essential for ensuring understanding and meeting regulatory requirements. Partnerships help improve care coordination, reduce readmissions, and enhance patient outcomes, which ultimately improves the financial health of the agency. By adapting to these changes, home health agencies will maintain compliance, improve patient outcomes, and achieve long-term financial success.
Tips for adapting to regulatory changes
Adapting to regulatory changes is challenging, but agencies can take several practical steps to optimize revenue and maintain compliance amid changing regulations.
By implementing these tips, agencies will optimize revenue and maintain compliance amid changing regulations. These investments help streamline operations success, ultimately leading to better patient outcomes and financial stability.
The MHA Difference
The post-acute industry is no stranger to regulatory changes, especially within the last few years. Things like PDGM, Quality Reporting, CoPs and overall CMS rulings consistently disrupt operational excellence in the agency setting. Adapting to regulatory changes while remaining knowledgeable and productive is challenging, luckily MHA is here to help. Our team is outfitted with industry veterans, knowledgeable in every facet of post-acute administration. Starting with an RCM assessment, MHA examines all facets of your billing process to understand how a claim is being managed. We’ll take a deep dive into any discrepancies to assess compliance and recommend corrective action. Our team provides the unique insight and knowledge to put your agency ahead of the curve, training your staff to remain compliant, while empowering your revenue cycle to operate at an unforeseen level of success. If you’re interested in a Revenue Cycle Assessment or want to learn more about your agency’s best course of action amid regulatory disruptions, contact us at [email protected] or visit www.maxwellhca.com.
1. Centers for Medicare & Medicaid Services. "Home Health Prospective Payment System (HH PPS) Patient-Driven Groupings Model (PDGM)." Accessed May 5, 2023. https://www.cms.gov/medicare/medicare-fee-for-service-payment/homehealthpps/hh-pdgm.
2. Centers for Medicare & Medicaid Services. "Home Health Agencies - Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs)." Accessed May 5, 2023. https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/homehealth.
3. Centers for Medicare & Medicaid Services. "Home Health Quality Initiatives." Accessed May 5, 2023. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/homehealthqualityinits.
4. Medicare.gov. "Care Compare." Accessed May 5, 2023. https://www.medicare.gov/care-compare/#search.