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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Improving Ambulatory Surgical Center (ASC) Collections

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With patients having more financial responsibility for their healthcare, outpatient settings like ambulatory surgery centers are becoming more attractive to patients. A research report from Bain & Co. estimates that the number of procedures taking place in outpatient surgery centers will rise from 23 million in 2018 to 27 million in 2021. As per the same report, out of all outpatient surgeries done in the year 2017, half were performed by ASCs. Now as things are settling down after the corona pandemic, these numbers are again looking realistic. Before getting prepared for this growth potential, you have to streamline your current ASC billing process. In this blog, we discussed Ambulatory Surgical Center (ASC) billing challenges and ways to counter them. We are confident that these tips will help in improving your Ambulatory Surgical Center (ASC) collections. 

Tips for Ambulatory Surgical Center to Improve the Patient Collections Process

Always Take Prior-Authorization

Prior to the date of surgery, always verify eligibility and benefits to understand coverage and determine the party responsible for payment. Always call the insurance company and as per your discussion with the insurance representative, if required, obtain prior authorization. Obtain pre-determination if prior authorization is not required. An insurance company may not process the pre-determination request, try to take approval for pre-determination based on medical necessity. In absence of prior authorization, an insurance company may not pay for offered services. Prior authorization is such a key element of ASC billing that you should have a dedicated team for doing eligibility verification and prior authorization.  


Looking for more information about Tips for ASC Billing click here: https://bit.ly/3DXpxo3. also you can get in touch with us at info@medicalbillersandcoders.com or call us at 888-357-3226.

Location: United States

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