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Helpful Tactics to Thrive Under PDGM


nurse using home health software to comply with PDGM requirements

As you may know, the Patient-Driven Groupings Model (PDGM) payment model went into effect on January 1. A recent industry survey by Axxess and home health consulting firm BKD confirmed PDGM is among the biggest concerns agencies have in 2020.

While we have heard that some clients are finding the new process to submit RAPs and get reimbursements from the Centers for Medicare and Medicaid Services (CMS) challenging, the vast majority of Axxess clients are smoothly making the transition to PDGM.

Axxess has had PDGM-specific features in our software since May 2019 and provided extensive training to our clients about these features and the overall impact of PDGM. We set up a rapid response team to assist clients through the transition.

PDGM Best Practices

As agencies get adjusted to the new requirements, there are a few things to keep in mind to help smooth the transition to two 30-day claims submissions for each 60-day episode of care. Below is a quick guide of processes to implement to ensure your operations and cash flow remain strong under the new PDGM standards:

  • Get your clinical and operational processes where they need to be quickly.
  • Make sure you’re continuing to communicate to your clinicians, referral sources and the physicians signing orders.
  • Your intake staff needs to be collecting a billable primary diagnosis.
  • Clinicians need to be completing thorough and accurate OASIS assessments quickly.
  • Quality assurance reviews should be performed quickly to ensure accurate information is included in all documentation and any process breakdowns are identified.
  • Be sure to communicate with physicians to ensure orders are signed in a timely manner.

You need all these things in place now so that you can bill the final claim as soon as possible after the end of the billing period.

Ask for Help with PDGM

It’s okay to ask for help. Don’t be afraid to outsource or rely on partners during the transition. There are experts who can help you shore up coding, billing and operational processes.

It’s still very early in the implementation of PDGM, and we are waiting to see exactly how CMS will handle this transition and whether their systems will work properly to process OASIS data, RAPs and claims. You should be checking daily for updates from CMS, especially during the first 90 days.

More strategies for revenue cycle success are available in Axxess’ white paper, “Timing is Everything: The Impact of PDGM on the Revenue Cycle.” More helpful information can be found in in our PDGM Resource Center.

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