pdgm graphic


PDGM is the biggest change for home health agencies in over two decades. The transition to the new model requires agencies to examine patient needs, comorbidities, and referral sources to determine if their case mix optimizes reimbursement. As case mixes change, agencies will need to take measures to ensure that their staff’s competency meets the level of acuity. For many, this paradigm shift is stimulating major internal changes to both optimize reimbursement and ensure quality care.

We Can Help


With the Patient-Driven Groupings Model set to take effect January 1, 2020, home health agencies across the country are preparing.

The largest change facing home health agencies in over two decades has many organizations evaluating and updating internal processes. Others are expanding their service lines to serve more clinically complex patients.

PDGM is leading to shifts in the way many agencies operate so they can maximize reimbursements under the new model. It can take time to hire new people or train current staff to provide high-quality care for these new types of cases.

To stay compliant with the model, your organization must have a plan for how you will provide care in the years to come.

Do you have the tools you need to thrive during the regulatory transition? If the answer is no, Relias has compiled a list of resources to see you through the implementation of PDGM.


New Regulations and Renewed Risks in Senior Care

Taking purposeful steps to train your staff on person-centered care will not only prevent abuse and neglect, but it will also position your organization for success as upcoming regulation changes begin to take effect.

Learn More

In Our Evolving PDPM/PDGM World, Could Adding a Specialty Be a Game Changer?

Adding a specialty to your repertoire in order to have more control, provide better outcomes, and work within the playbook you’ve been given will be the matter at hand.

Learn More

Top Questions About PDGM’s Impact on Billing & Finance Answered

See the answers to the most frequently asked billing and finance questions regarding the Patient Driven Groupings Model.

Learn More


  • When questionable encounters are discussed, does this refer to when these codes are included with other codes or only on their own?

    Questionable Encounters (QE) refer specifically to the primary diagnosis on the claim. Diagnosis codes that would qualify as a QE in the primary diagnosis spot can be listed as a subsequent diagnosis on the claim. The main concept here is that these diagnoses represent a symptom of the patient’s condition but on their own do not constitute home health eligibility.

  • How will PDGM impact MSP?

    The general concepts of medicare secondary payer (MSP) billing will remain the same under PDGM. Providers will have to adapt the use of the existing MSP billing codes to the new PDGM claim format.

  • Will CMS be paying requests for anticipated payment in a timely way so that an agency can process billing promptly for the 30-day final claim?

    There has been no indication that the processing time for RAPs (typically four to five days) will change under PDGM. We recommend, however, that providers monitor processing times over the first couple months of 2020 in case the RAP processing time is impacted by updates made to the Medicare system for PDGM.

  • Why will it take three to four months for the cash flow to return to normal?

    The projected cash flow delay is impacted by a few issues. First, it is anticipated that adapting to the new PDGM system will result in billing delays for providers due to the shortened timeframe for resolving prebilling issues and limitations in the EMR PDGM setup. Historically, Medicare has also shown delays in claims processing when making system updates of a much smaller magnitude than PDGM. It is not guaranteed that this will occur during the PDGM implementation, but providers should be aware of the potential delays. Finally, National Association for Home Care & Hospice (NAHC) performed an independent review using example cases for PDGM periods starting on various dates. This analysis found that in most cases agency cash flow would not return to pre-PDGM levels until approximately March 2020. The impact will be different for each provider, but our recommendation is that providers prepare for this potential risk.

  • How is PDGM going to affect agencies who have "therapy only" patients?

    The decision-making on discipline/visit utilization should not change under PDGM. The plan of care should still be designed to meet the service needs of the patient. If this dictates that the patient only needs therapy services, then the service delivery should not be different than it was under PPS. Providers will have to evaluate, however, the anticipated change in revenue for this service category under PDGM compared to the Prospective Payment System. We also recommend that providers evaluate their patient mix as a whole to determine if it is sustainable under PDGM, especially if this patient mix involves a high therapy need.

  • I am concerned that CMS determinations of early and light, and community and institutional referrals may be delayed if a hospital does not file its claims in a timely manner. So, a home health patient might be taken as an early institutional patient, and then CMS might later determine just the opposite once the hospital files its claims. Would this not negatively affect home health agencies?

    Home health agencies will submit the claim based on the information they have at the time. CMS will be looking through the common working file to validate those. There may be times when a provider submits a claim classifying a client as an institutional admission when that is not the case because the visit turns out to be an observational stay instead of an inpatient stay. CMS might then come in and automatically reconcile payments for the home health agency. That certainly does create some conflict and confusion within the new model that isn’t in the existing model today. Unfortunately, there’s no way to deal with this type of circumstance other than how CMS has approached it unless the home health agency wants to wait months until the provider of hospital services submits the claim.

    So the home health provider shouldn’t wait to submit the claim. Home health agencies should submit claims based on the knowledge they have at that time. They also should build into their budgets and their revenue recognition the potential possibilities of reductions in payment (increases in payment too). Most of the reconciliation will likely come down to coding to recognize the updated information.


Home health care agencies are challenged to develop and implement a plan to meet all the requirements of PDGM and optimize reimbursement. Relias has the tools that can help you properly train your staff, standardize your processes, and manage your staff’s development.

  • Correct Coding: Quick and accurate coding is critical under PDGM. Relias offers OASIS-D and ICD-10 training for your staff.
  • Adapt and Develop Skills: Look at the common needs of your referral sources, and use Relias Assessments to identify your baseline competency in those areas. Then you are ready to provide targeted education to develop competency across the organization.
  • Change Management: Relias offers education and tools, such as Policies & Procedures Management, to help ensure a smooth transition and adoption of the new practices.
  • Convenient Access: Stop wasting time looking for that one piece of paper in the folder you can’t find. Our online platform will streamline training, tracking and reporting, keeping all your documentation in one place.
Prepare Now