Legislation Eliminates 6.4% Negative Impact of Behavioral Adjustments in PDGM

Republican Sen. John Kennedy of Louisiana introduced S. 3458 seeking to remove the controversial behavioral adjustments. The bill is co-sponsored by Sen. Bill Cassidy, also a Republican from Louisiana. The legislation takes aim at the behavioral adjustment of Patient Directed Groupings Model (PDGM), which have been opposed by many home health stakeholders including VNAA and ElevatingHOME. Behavioral adjustments were added because of the assumption 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 unnecessary visits.

Among its provisions, S. 3458 seeks to prohibit CMS from making rate adjustments based on behavioral assumptions. The measure likewise seeks to require CMS to institute rate adjustments only after home health agency behavioral changes have actually occurred and  basing those adjustments on observed evidence instead of speculation.

To ensure budget neutrality, the bill also requires that the phase-in of any necessary rate increases or decreases be no greater than 2 percent per year to limit potential disruption in patient care.

Please contact Joy Cameron with any questions.

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