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New Senate Bill Takes Aim at PDGM

Posted on Monday, September 24, 2018 1:10 PM

A new federal bill introduced last week takes aim against the proposed Patient-Driven Groupings Model (PDGM) behavioral adjustments, which have been fervently opposed by many home health stakeholders.

“Floated by the Centers for Medicare & Medicaid Services (CMS) in early July, PDGM overhauls the home health prospective payment system by removing perceived incentives to over-provide therapy services and halving the standard 60-day unit of payment. Besides those two major changes, however, PDGM also includes the so-called “behavioral adjustments,” or measures CMS assumes agencies will take in light of the new framework.

Behavioral adjustments, for example, assume that agencies will change documentation and coding practices to get the most in reimbursement under PDGM. They also include CMS’ prediction — not based on any real-world observations or pilot programs — that agencies will actively look to avoid Low Utilization Payment Adjustment (LUPA) claims by adding any necessary visits.”

“I think behavioral adjustments are something that this industry really shouldn’t tolerate,” Paul Kusserow, president and CEO of Amedisys said at the 2018 Home Health Care News Summit in Chicago. “The idea that [CMS] knows what we’re going to do, particularly if it’s bad, even before we do it is just wrong.”

Backed by Amedisys, the National Association for Home Care & Hospice (NAHC) and other industry players, Republican Sen. John Kennedy of Louisiana introduced a new bill last Tuesday — S. 3458 — seeking to remove the controversial behavioral adjustments. The bill is co-sponsored by Sen. Bill Cassidy, also a republican from Louisiana.

Among its provisions, S. 3458 seeks to prohibit CMS from making rate adjustments based on behavioral assumptions.

 “If you don’t want to live with this cut, then call your congressmen, call your senators, and say you support this bill,” Kusserow said to summit attendees. “This is really important because what it says is, ‘Don’t [dock] us 6.4% in 2020.’ Don’t do that to us.”

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