LUPAs and reimbursement

[anticoagulationurse]

I understand that a LUPA is a reduced reimbursement based on fewer than 5 visits in an episode. I understand that the reimbursement for a LUPA is per visit (not sure the rate), instead of one large lump sum for the entire episode (no matter how many visits, or is it graduated based on number of visits?).

It seems to me that most episodes with mixed disciplines that are NOT LUPAs net about $2500+/- per patient per episode. If the reimbursement is a "mere" $200 per visit on a LUPA (again not sure of the rate), how in the world is the company losing money on a LUPA?! Management keeps pushing this issue as though we are literally losing money each visit when a nurse sees a patient that turns out to be a LUPA. However, are they not getting reimbursed a nice little chunk of money for each of those visits? I sure as heck know that I don't cost them $200 per visit, and gas mileage rarely is very high. So where exactly is the loss? It seems it is more a perceived loss of potential reimbursement, not actual loss/expense.

It seems to me by comparison, that there must be a "sweet spot" regular/most cases in which a LUPA does not occur. If lump sum reimbursement is a set amount, say $2500 per 60 day period, then you would assume the division of visits needs to be optimal in order to not "lose money" on having too many visits. If the reimbursement per visit is $200 contrasted with the episode payment of $2500, divide the $2500 by $200 and it seems to me the sweet spot for number of visits in an episode is 12. Any more visits than that and the reimbursement per visit is less that what the company would get for a LUPA, and and less would just be money in the company's pocket. Any number of visits between 5 and 12 and the company is making money. I could be totally off and too simplistic on my numbers but, how could we lose money at all, in any way when we are seeing a patient?

[4evernrs]

I don't know the exact figure, but I do not think that a LUPA per visit reimbursement is anywhere near $200. I'm thinking that it is probably about half of that. (Does anyone know the figures???) You also have to consider all the overhead that goes into securing the referral, processing the admission, scheduling, QA and billing staff. To some extent I'm sure that the "loss of potential revenue" is wrongly termed "losing money", but in a sense, it very likely is a loss after all the work that is involved in a LUPA episode.

[KateRN1]

If I remember correctly, the per-diem rate is about $120. As stated above, if you take into account all of the overhead that is required to even start that patient, then LUPAs do indeed lose money.

[Lacie, BSN, RN]

Consider with lupas there are times it cost more in the long run for the company as by the time they pay the disciplines that did manage to get in the door and the processing, etc that goes with it. They may make a little bit in the end but they still have to pay out. Nurse and pt goes to home makes a visit, pt after 2 visits doesnt want any more care - believe me the company has already paid out more than they will be reimbursed after all the other budgetary cost are considered all the way down to paper cost. Pretty simple - very low profit and most HHC are Profit making companies (heck most health care is now adays)

[anticoagulationurse]

Thanks for the replies. I guess it all depends on what the reimbursement rate is, and that I don't know.

[caliotter3]

I did an internet search and found at least a few links that provided the current reimbursement rate.

[anticoagulationurse]

Well I sure didn't find the information quickly or easily but here's what I found:

2010 RATES

The rule sets out the 2010 rates for the base episode, Low-Utilization Payment Adjustments (LUPAs), LUPA add-on, and medical supplies conversion factor. Consistent with the application of a 2% inflation update (Market Basket Index), the scheduled 2.75% case mix creep adjustment, and a new dramatically altered outlier policy that returns 2.5% to base rates, the overall base rate increase is set at 1.75%. The LUPA rates are increased differently because of the inapplicability of the creep adjustment and the outlier budget shift.

This leads to the following results:

Base Episode Rate: $2,312.94

LUPA Add-on: $94.72

LUPA Visit Rates: $51.18 home health aide

$181.16 medical social services

$124.40 occupational therapy

$123.57 physical therapy

$113.01 skilled nursing

$134.27 speech language pathology

Medical Supplies:

$14.39 Severity Level 1

$51.96 Severity Level 2

$142.48 Severity Level 3

$211.69 Severity Level 4

$326.43 Severity Level 5

$561.42 Severity Level 6