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Physician + Specialty Practices

Best practices for new PDGM home health rules

PDGM took effect Jan. 1: get 3 tips for success in the new home health landscape

Launched as a result of the Bipartisan Budget Act of 2018, the new Patient-Driven Groupings Model (PDGM) is designed to support better reimbursement for home health patients while eliminating subtle enticements to provide excessive therapy services. While the new rules help ensure home healthcare can keep pace with the larger industry’s transition to value-based care initiatives, the new landscape will also disrupt operations for home health agencies (HHA) of all sizes. In fact, we expect to see some of the biggest changes to the home health industry in 20 years.

With claims volume expected to nearly double, HHAs everywhere are working overtime to ensure the transition is as seamless as possible. With the new year around the corner, it’s time to prioritize the critical areas in your operations that will be most affected by the change.

Want to make sure you’re ready? Here are three critical issues you’ll want to make sure you address.

  1. Your claims workflows are inefficient
    Under PDGM, claims will now have to be submitted every 30 days instead of every 60. If your claim workflows are already problematic, just imagine how tricky things will get once your workload accelerates.


    Look to automation to help your team increase productivity with less administrative waste. Especially if your resources are stretched thin, automating manual tasks and improving visibility are surefire ways to improve processing time without hiring new staff.
  2. You’re unclear on the status of your KPIs
    If you’re going to understand just how heavily PDGM will impact your operations, you need to develop a clear picture of where your KPIs are today. Without a firm understanding of that data, your productivity and performance are destined to take a hit.

    Complete a thorough analysis of your current data and highlight trouble areas. The most critical things to focus on include:
      Days to request for anticipated payment and final claim
    •  Percentage of RAPs cancelled
    •  Low utilization payment adjustment percentage by threshold
    •  Cost per episode and cost per visit
    •  A/R days
    •  Denial rate
  3. You haven’t confirmed coding accuracy under the new rules
    Under PDGM, the Centers for Medicare & Medicaid Services project roughly 15% of encounters will have to be classified as questionable encounters (QE) and won’t be reimbursed. If you don’t have a firm grasp on the new coding guidelines, you’re going to lose revenue.
    Analyze historical encounters to build an understanding of what qualifies as a QE under PDGM. Review examples and work with staff to help them understand what went wrong and talk through what the appropriate primary diagnosis should have been.
What’s next?

A new day in home healthcare is on the horizon. With the right preparation and guidance, your organization can flourish in the new regulatory landscape.

Want to learn more about PDGM and how it will affect your organization? Check out our PDGM for home health resource center to see a readiness checklist, watch a preparatory webinar and more.

Waystar PDGM checklist

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