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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General Surgery Medical Coding Steps to Avoid Denials

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Physicians in general surgery are facing an uphill task of medical billing keeping in check the different needs of the facilities and keeping a tab on the effective revenue cycle management to look for frequent denials and which of the claims need more efficient coding. The channel of insurance payment has been one of the most straining factors for general surgery physicians today affecting the bottom line of the revenue and in turn affecting the facility.  Individual physicians have the high cost of staffing and also revenue management which has led to many of them being absorbed by groups acquired by the hospital. General Surgery is one such facility that has seen a rise in individual costs and most of the facilities are either in the group or combined with hospitals.

Tracking different types of patient care from appointment scheduling to registration and different steps for collection of the balance fall under the revenue cycle management. The healthcare revenue cycle is a financial system that has brought in the work of administrative and clinical functions associated with billing. The process happens to take into consideration different data points which are coded into a format that helps the understanding of an insurance company. These codes are usually laid by the Center for Medicare and Medicaid Service (CMS) and also the price value of each procedure or diagnostic is decided beforehand to help cover the cost and also a margin of profit for the doctors.

If you want to read the complete blog then click below: General Surgery Medical Coding Steps to Avoid Denials


Location: Louisiana, USA

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