Home Health Agencies: Here's Why PDGM Payments Keep Falling Short

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Home health agencies can provide the right care, submit claims on time, and still see Medicare reimbursement come in lower than expected. The reason is often not simply a billing error. Under the Patient-Driven Groupings Model (PDGM), reimbursement depends on several factors, including the patient's clinical characteristics, functional needs, comorbidities, timing of the period, and whether the period meets the requirements for a full 30-day payment. For 2026, CMS also finalized changes to PDGM case-mix weights, functional impairment levels, comorbidity adjustment subgroups, and Low-Utilization Payment Adjustment (LUPA) thresholds. CMS also finalized permanent and temporary payment adjustments for home health. That means a reimbursement drop deserves more than a quick review of the claim amount. The real question is: What changed between the care provided and the payment received? How PDGM Determines Home Health Payment PDGM uses a 30-day period of care rather than the older 60-day...
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5 Common Mistakes Physicians Commit with their Family Practice Billing

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The family practice medical service is all-encompassing and involves more than one field of medicine. Ideally, medical billers who work for family practice need to have extensive knowledge of diagnosis and procedure codes commonly used by the physician. This ensures that patients and insurance companies are billed correctly. It also guarantees that the physician receives maximum reimbursement for the service provided.

Basic Mistakes in Family Practice Billing:

1. Neglect to verify their patient’s Insurance:

Very often medical billing claims get refused on the basic ground that the patient’s coverage has been terminated or may not be eligible for the date of service. Family physicians often take for granted that their regular patient, whose insurance had been verified initially, stands the same every time they come in. This may not always be the case.

2. Simple inaccuracies during form filling:

Often family physicians are so occupied with putting their regular patients at ease that they tend to forget about filling the simplest and smallest of details right from the spelling of the patient’s name to whether the diagnosis code corresponds to the procedure being performed. This causes claim denials or at the very least delays in reimbursements
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