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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Declaration of Blanket Waivers for SNFs

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On 7th April 2022, in response to the COVID-19 PHE and under section 1135 of the Social Security Act, CMS passed several temporary emergency declaration blanket waivers which were intended to provide health care providers with extra flexibilities required to respond to the COVID-19 pandemic. While the waivers of regulatory requirements have provided flexibility in how nursing homes may operate, they have also removed the minimum standards for quality that help ensure residents’ health and safety are protected. 

Declaration of Blanket Waivers

Recently, CMS conducted some surveys that revealed significant concerns with resident care that are unrelated to infection control (e.g., abuse, weight loss, depression, pressure ulcers, etc.). Waiver of certain regulatory requirements may have contributed to these outcomes and raised the risk of other issues. For example, by waiving requirements for training, nurse aides and paid feeding assistants may not have received the necessary training to help identify and prevent weight loss. Similarly, CMS waived requirements for physicians and practitioners to perform in-person assessments, which may have prevented these individuals from performing an accurate assessment of the resident’s clinical needs, contributing to depression or pressure ulcers. As a result, CMS has terminated certain waivers.

In this blog, Our Medical Billers and Coders shared emergency declaration blanket waivers for certain providers in SNFs. Looking for more information about Declaration of Blanket Waivers for SNFs click here: https://bit.ly/3xJKyyU. also you can get in touch with us at info@medicalbillersandcoders.com or call us at 888-357-3226.


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