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2 Day Medicare Workshop

Speaker(s): Melinda A. Gaboury, CEO

Category: Speaking Engagement

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Speaker(s): Melinda A. Gaboury, CEO

About the Speaker(s)

Melinda A. Gaboury, with more than 29 years in home care, has over 20 years of executive speaking and educating experience, including extensive day to day interaction with home care and hospice professionals. She routinely conducts Home Care and Hospice Reimbursement Workshops and speaks at state association meetings throughout the country. Melinda has profound experience in Medicare PDGM training, billing, collections, case-mix calculations, chart reviews and due diligence. UPIC, RA, ADR & TPE appeals with all Medicare MACs have become the forefront of Melinda’s current impact on the industry. She is currently serving on the AHC/HHFMA Advisory Board and Work Group and is Treasurer on the Home Care Association of Florida Board of Directors. Melinda is also the author of the Home Health OASIS Guide to OASIS-D1 and Home Health Billing Answers, 2021.

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2 Day Medicare Workshop Apr 12 - Apr 13, 2022
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About the Event

Medicare Home Health Reimbursement Workshop – Day 1 

The Patient Driven Groupings Model (PDGM) went into effect January 1, 2020. This is the most massive change to the home care industry reimbursement structure since the introduction of the Prospective Payment System (PPS) in October 2000. The new payment model has dramatically impacted agency operations, processes and performance. January 2022 brought even more changes with the Notice of Admission (NOA) replacing the NO Pay RAP.  This workshop will have a focus on best episode management and process improvement practices including the referral, intake and scheduling processes, timely documentation, physician and patient communication strategies, all of which are required to more tightly manage care within the shorter 30-day payment period. The change to a 30-day payment model has brought significant back-office changes, specific to the claims processing and collections, which will be one emphasis of this workshop.  A strong clinical episode management program is critical to ensure sustained, efficient, cost-effective and uncompromised quality care delivery under the PDGM program!  Lastly, this workshop will review the full-blown emphasis of ICD-10 coding under PDGM and how agencies will have to monitor to ensure the specificity of coding for their patient care plans.   


Program Topics 

Detail the current PDGM Model and Lessons Learned 

  • Outline the HIPPS code make up 
  • Define Case Mix categories under PDGM 
  • Review Admission Source and timing  
  • Review findings of current data under PDGM 

Evaluate the PDGM Structure & Financial Impact  

  • Establish HHRG/HIPPS codes & corresponding case‐mix weights  
  • Define how the determination of a Low Utilization Payment Adjustment is made 
  • Review PDGM financial estimates that CMS made and a review as compared to actual occurrences so far 
  • Review the ADL section of the OASIS and how the points and calculations have changed in 2022 

Summarize key Revenue Cycle Operations affected by PDGM changes. 

  • Explain scheduling strategies to prevent penalties for Late NOAs in 2022 and forward 
  • Discuss necessary modifications to the intake and referral process under PDGM 
  • Review strategies for improved physician interaction to ensure timely 30-day billing 
  • Explain the importance of clinical review of each 30-day payment period under PDGM 

Review the Impact of ICD-10 coding under PDGM 

  • Explain the relevance of timely coding completion and clinician documentation under PDGM 
  • Evaluate the specificity requirements of coding under PDGM 
  • Outline the Impact on case-mix weight with one code versus another 
  • Detail the process for calculating the HIPPS code from the coding aspect 



Medicare Home Health Reimbursement Workshop – Day 2 

In addition to all the basics of the PDGM Model and the billing that comes with that, the Medicare Advantage component is a very real concern, and this session will discuss the details of dealing with Medicare Advantage.  In addition, this day will include as much detail as is available concerning the coming implementation of the Home Health Value-Based Purchasing Model.  The full implementation is set for January 2023 and looks to be maddening for all concerned. Medicare Medical Review has a direct impact on revenue cycle if an agency gets involved in a third-party claim review situation.  Much of the decision surrounding putting an agency on Medicare Medical Review is based on statistics such as the PEPPER Reports.  This day will include a full review of the PEPPER reports and how to analyze your PEPPER and determine what can be done to adjust the results for the future.  This full day will be composed of multiples elements of all that an agency needs to survive and maintain the  

Program Topics 

Review Home Health Value Based Purchasing  

  • Detail the calculation process and statistics from the demonstration for Home Health VBP 
  • Review what agencies should do to prepare for nationwide rollout coming in 2023 
  • Detail the calculation of the Total Performance Score – Improvement & Achievement 
  • Review examples of the Linear Exchange Function calculation used to determine impact on future payments 
  • Detail the functional M1800 items included in the Composite Mobility Measures 

Medicare Advantage – Credentialing 

  • Review the current landscape of managed care across the country;  
  • Detail the challenges of operations in the managed care environment; and  
  • Detail the process of becoming credentialed with Medicare Advantage Organizations  
  • Apply solutions to the managed care obstacles 

Home Health Medical Review 

  • Detail the review contractors & the experiences – UPIC, SMRC, MAC ADR, RAC & Targeted Probe & Educate 
  • Review the process of responding and assembling the records for submission 
  • List the Top 5 reasons for denial and how to avoid them 

Home Health PEPPER Reports  

  • Detail the significancy of the PEPPER data 
  • Outline the PEPPER data that is gathered strictly from the from processed claims information 
  • Review how home health agencies should be heightened aware of their PEPPER data 
  • List the key elements in the PEPPER targets  
  • Establish the use of PEPPER data in Medical Review decisions