PDGM-Patient Driven Grouper Model. Biggest change in 20 years.
In November 2018, CMS finalized a new case-mix classification model, the Patient-Driven Groupings Model (PDGM), effective beginning January 1, 2020. The PDGM relies more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment categories and eliminates the use of therapy service thresholds. In conjunction with the implementation of the PDGM, there will be a change in the unit of home health payment from a 60-day episode to a 30-day period.
- Interactive Grouper tool on HHA Center webpage
- PDGM Case Mix Weights and LUPA Thresholds [ZIP, 45KB] and PDGM Agency Level Impacts [ZIP, 938KB]
- CY 2019 Home Health Final Rule on Federal Register
- MLN Matters Article MM11081- PDGM – Split Implementation
- PDGM – Split Implementation – Change Request 11081
- Home Health Patient-Driven Groupings Model National Provider Call – February 12, 2019
Review Choice Demonstration
Illinois Started in June 2019.
Initial Choices are the following:
- Pre-claim review: 90% approval in 6 months to be removed
- Postpayment review:90% approval in 6 months to be removed
- Minimal postpayment review with a 25% payment reduction. (Could bring additional oversight) Not recommended
CMS will continue to post updated information on this website. In addition, CMS and Palmetto GBA will provide at least 60 days’ notice prior to the demonstration start date in each of the additional four states. CMS will provide notice on this website before phasing in the other demonstration states: Ohio, Texas, North Carolina, and Florida. Please send any questions to: homehealthRCD@cms.hhs.gov.
Claims Issues Log
Medicare realized they have been paying incorrectly Home Health Claims. Your Home Health Billing Services Company “Synergy Consulting” is able to find the claims where Medicare owes reimbursement.
Medicare will correct the Home Health Billing Claims.
Medicare contractors have identified two incorrect payment calculations affecting home health claims. Claims reporting Health Insurance Prospective Payment System (HIPPS) codes are receiving an incorrect case-mix weight that results in underpayment. Also, certain claims that would be eligible to be paid low utilization payment adjustment (LUPA) add-on amounts are not receiving the add-on payment. CMS expects Medicare systems to be corrected soon. Home health agencies do not need to take any action. Medicare Administrative Contractors will adjust the claims to correct payments.
Home Health Medicare Billing Agencies Time for Cost Reports Again
Congressional Letter Opposing Face-to-Face Documentation Requirements Sent to CMS’ Administrator
Home Health Medicare Billing Agencies Time for Cost Reports Again. They are due by June 1 of this year. You can request from Synergy Consulting to retrieve your PS and R (Provider Statistical Reports) from the CMS Portal login.
Make sure that your CPA has your PS & R. If not you will need to gain access to your IACS account to run your PS & R. IF you need assistance in creating IACS account. Please contact us at Synergy Consulting – Your Home Health Billing Services Company.
We recently updated the filing location of JM provider cost reports. All JM Part A and JM Home Health and Hospice (JM HHH) providers and corresponding home offices should now file their cost reports to the Columbia, South Carolina office location. Cost report reminder letters will be updated to reflect the change in filing location. These letters are sent approximately 37 days before the cost report is due.
Checks and correspondence relating to amounts due on cost reports should be mailed separately. This address is provided below as well.
Cost Report Address Information – Columbia, South Carolina.
For Cost Reports and Supporting Information
Mailing Address for U.S. Mail Palmetto GBA
Attn: Cost Report Acceptance (AG-330)
P.O. Box 100144
Columbia, SC, 29202-3144
Mailing Address for Courier Service Palmetto GBA
Attn: Cost Report Acceptance (AG-330)
2300 Springdale Drive, Bldg. One
Camden, SC 29020