HCAF: Home Health Hot Topic: LUPAs, PEPs, Outliers & Institutional Credit – PDGM Adjustments

At the conclusion of this program, the participant will be able to:

• Understand the intricacies of Medicare reimbursement in home health care, including the impact of factors such as OASIS validation, payment period timing, and admission source on claim payments.
• Comprehend the Patient Driven Groupings Model (PDGM) and its implications for payment calculations, particularly regarding admission source, timing, clinical grouping, comorbidities, and functional scores.
• Learn how to accurately determine the HIPPS code based on clinical grouping, comorbidities, and functional status, and understand its significance in claim payment.
• Gain insight into the recalibration process of PDGM case-mix weights and Low Utilization Payment Adjustment (LUPA) thresholds, and understand how these adjustments affect payment for different types of patients served by Home Health Agencies (HHAs).
• Understand the concept of Outlier payments in home health care, including how they are determined based on estimated cost, wage-adjusted standard fixed loss threshold amount, and loss sharing ratio, and how they impact overall reimbursement under the HH PPS.