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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Guidelines for Reviewing your Billing Manager’s Performance

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Billing Manager's performance goals and objectives to elevate job satisfaction and productivity. Billing Manager SMART goals to achieve success! Conducting performance analysis has been an age-old practice by many businesses worldwide. However, we come across many such physicians, solo and group practices, who do not feel the need to have any assessment and review done for their billing or accounts manager’s job. This can give rise to many of the following problems that are experienced:

  • A billing manager does not have his/her clear statement of criteria for performance. In such situations, the billing manager puts forth criteria that seem good enough for the entire billing team. The problem is, there may be some area that needs the physician’s attention, which is many a time neglected. This results in a lack of oversight regarding billing and collection activities- which is the main lifeline of the practice.
  • Secondly, a physician does not have any clear idea of the manager’s job. For instance, we have seen physicians who reviewed their EHR without any consent and involvement of the billing manager. The possible integration of the EHR systems into the A/R system coveys a high priority in the investigation. Hence the billing manager should be a part of the study even if he’s not heading it.
  • Many a time, the physician’s attitude is, as long as the practice is performing well, the billing manager is assumed to be functioning properly. But when this is not the case, the physician will likely blame the billing manager. In group practices, it is seen that different medical physicians have different interpretations regarding the manager’s performance.

The First Important Step

Are all of the billing guidelines relevant to your billing manager’s position? Both practice physicians, as well as the billing manager, should spend time reviewing the guidelines.  For instance, in many smaller practices, the billing manager does an annual budget. Again, some smaller-practice managers are very much intricate in negotiating with managed care plans. And in a few practices, a part-time bookkeeper or even a practice owner’s spouse, has the accounts payable work being done. Therefore the guidelines should be modified, as seen fit for your practice.

The Advantage For Billing Managers

Billing managers will find this type of evaluation very useful for their work. First, they can get a better picture of goals related to each of the many tasks in the manager’s job. Second, these guidelines can be used for self-evaluation. Third, they can feel comfortable that their physician bosses will use the same criteria in evaluating the manager’s performance.

Physicians Involvement

Practitioners and hospitals should closely review and learn the guidelines. Then, in concurrence with the billing manager, they should modify any of the required guidelines for their practice. Once that agreement has been negotiated, it would probably be feasible to consider an initial evaluation in three to four months. Subsequently, it could be done annually.

Physician Involvement in the Manager’s Review

In any group practice, every physician should be provided with an evaluation form to review. In group practices, one physician should be the adviser of these evaluations. The purpose of the review is not to provide a progress card. Rather it is, first, to understand those tasks that are “meeting goals” and “better than goals.” These merits are acknowledged and commended to the manager. Lastly, notable attention should be addressed to any tasks not meeting the goals. These things need a very close study. The physician should aim for answers to help solve the low-performance tasks.

To know more about Guidelines for Reviewing your Billing Manager’s Performance, click here: https://bit.ly/44YCXuk Contact us at info@medicalbillersandcoders.com/ 888-357-3226.

Location: United States

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