What are legal and business ramifications caused by the Patient-Driven Payment Model for organizations providing Medicare-covered senior services?

Litigation risks will increase under PDPM because the individuals you serve will be more medically complex. Also, many lawyers will monitor the documented care prior to and after PDPM participation. Plaintiffs’ attorneys often try to establish that you did not provide the most appropriate level or type of care.

If you Google PDPM, you and your staff probably could find numerous webinars to guide you on what to do to prepare for PDPM. Compliance will require constant updating and continuous education as the Centers for Medicare & Medicaid Services implements this sweeping new payment program.

Remember, too, that PDPM will continue to evolve as other payers use PDPM methods to reduce their costs and improve their quality of care. 

Providers will need to merge, joint venture or consolidate to better position their organizations to take advantage of opportunities under PDPM. Like all other major changes in reimbursement systems, PDPM ultimately will be modified to respond to unintended consequences caused by its implementation. 

PDPM also rewards service providers who can make a cultural shift in care delivery models supported by technology. The PDPM rate is based on several factors: physical therapy, occupational therapy, speech therapy, nursing care services, non-therapy ancillaries (NTA) and non-case-mix services (such as housing and food).  

NTA costs are not captured well on MDS forms so you must monitor and document those services to your seniors. ICD-10 coding is very important to the PDPM program.

Please send your legal questions to John Durso at [email protected]