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The financial benefits of using data and analytics to navigate the PDGM waters

PDGM holds home health and providers accountable for achieving a better balance between care quality and the associated claims cost. This balancing act calls for better performance measures of care delivery and coordination throughout the care continuum. A method to ensure this oversight is using data and analytics that proactively identify trends in the billing process. The consequence for not having the right level of oversight could be noncompliance with PDGM standards and ensuing penalties, as well as significant revenue losses.

Data and analytics can deliver a comprehensive view into a home health agency’s reimbursement process. The data collected enables a home healthcare provider to make recommendations that lead to actionable steps to improve trends. Think about some of the key areas that impact the home health reimbursement process, such as:

  • Average days to submit RAP
  • Average days to final claim
  • Average LUPA rate

Transactional reporting does not adequately identify trends that can impact revenue generation. Plus, the process of unraveling so many layers of data can be laborious. This process doesn’t just create an unnecessary administrative burden; it also leaves room for costly errors. A data and analytics tool offers several advantages to a home healthcare provider, especially as it relates to PDGM. Let’s take the abovementioned key areas and get a sample view of how we can use data and analytics to navigate the PDGM waters and gain greater visibility into a home health agency’s productivity and performance.

Average days to submit RAP

According to CMS, a home health agency must have its RAP submitted and accepted within five calendar days or be subject to a financial penalty. A data and analytics tool can reveal where an agency will incur financial penalties for falling outside the designated timeframe. This identifies areas where corrective action is necessary for penalty cost avoidance. For example, if the average days to submit RAPs for all units were within the 5-day goal but one rose to 9.5 days, there’s an opportunity to assess this specific unit and untangle possible causes. The data helps pinpoint any trends or outliers (e.g., one patient or claim) that potentially could have caused things to go awry.

Average days to final claim

When it comes to billing and reimbursement, home-based care providers should understand how long it takes to get the final claim out the door. This ultimately determines when they can expect payment. Home health agencies must submit a final claim at the end of each 30-day period. Because providers will now only receive one payment on the final claim, it is important that billing occurs promptly—as close to the end of the billing period as possible. Leveraging PDGM-related benchmarking data in real-time can help to highlight what steps are necessary to secure acceptable physician signatures for the plan of care and other orders that occurred within the period. With final claims billed expeditiously, home healthcare providers are less likely to experience a delay in cash flow.

Average LUPA rate

Billing occurs in 30-day intervals, but there are different types of billing periods. Home health agencies must understand what percentage of billing periods were LUPAs, as these can result in significant revenue losses that mount over time. If an agency’s average LUPA rate climbs from roughly 10 percent to 24 percent, having timely access to data trends allows you and your team to ask the right questions. Could it be that your agency was treating a different type of patient? Could it be due to a staffing shortage caused by COVID-19 that resulted in care delays? Consequently, a provider is equipped to make the necessary changes at the right time.

How agencies can use data and analytics to navigate the PDGM waters

The changes implemented by PDGM have impacted how home healthcare providers operate. PDGM has also forced them to reassess healthcare delivery within their organization. PDGM has many nuances, which can present many challenges and unanswered questions for organizations. From payment ambiguity to shorter payment periods, the inability to comply with PDGM regulations can lead to financial penalties. Providers also cannot overlook the fact that regulatory changes are happening as the home health industry continues to recover from the disruption caused by the COVID-19 pandemic. Yet, providers should comply with the standards set by the billing and reimbursement model.

Having accurate insights into your home health organization is more important than ever. MatrixCare has been at the forefront of helping home-based care providers navigate these regulatory changes. Our analytics solution, MyAnalytics, is updated nightly for meaningful insight into a provider’s healthcare trends and patterns. This data and analytics tool helps providers make more informed decisions that improve health outcomes. It also helps facilitate the seamless transition to the new reimbursement model. Like any data and analytics platform, MyAnalytics cannot answer all the questions related to PDGM. Instead, it can equip home healthcare providers with data that tells them which questions to ask. And providers use that data to take practical steps that drive reimbursement and revenue growth based on PDGM standards.

Find out more about using data and analytics to navigate the PDGM waters here.


Amy Anderson
Amy Anderson

Amy is a Senior Product Manager at MatrixCare and has over 20 years of experience in home-based care technology. With a laser focus on data and analytics, Amy helps providers optimize their clinical operations.


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