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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Tips for Behavioral Health Billing

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Optimization of your billing process is an opportunity to make behavioral health practice more manageable. It’s not a secret now that the less time you spend on managing your medical billing, the more time you can focus on your clients to give them proper treatment for their issues. Any practice will get benefitted from streamlined medical billing processes, like fast reimbursement, and increment in cash flow.

Although, billing can be overwhelming to know what process developments will have the main impact on your practice.

Looking for more information about Tips for Behavioral Health Billing click here: https://bit.ly/3dLDFGq. 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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