I’m thinking there’s a lot of mixed messages from insurance companies, and guidelines/reimbursement are probably influenced by who you have direct contracts with. We pretty much do the opposite of Marnie – for example, we bill RAP and Final for BCBS Medicare and BCBS MSHO (Medicare) and get paid according to CMS rates. For Humana, United Health Care Medicare Advantage, and UCare Medicare we bill PDGM coding on a Final claim only that is per calendar month, not per 30d period, and get paid our contracted per visit rate (not CMS rates). So confusing – I wish there was a one-size-fits-all answer, but it doesn’t seem that way – at least not yet. Maybe things will improve??

 

Kori

Pathways to Achievement

Duluth MN 55806

 

From: billers@list.mnhomecare.org <billers@list.mnhomecare.org> On Behalf Of Marnie Pogreba
Sent: Wednesday, August 19, 2020 9:29 AM
To: billers@list.mnhomecare.org
Subject: RE: PDGM vs non-PDGM

 

These are the pay sources that I bill using PDGM.

 

Humana

BCBS Medicare Advantage – (does not require a RAP just a Final).

BCBS MSHO (Medicare) – (does not require a RAP just a Final)

Tri Care

United Health Care Medicare Advantage

 

 

Marnie

Lakewood Health System

 

From: billers@list.mnhomecare.org <billers@list.mnhomecare.org> On Behalf Of Tuma, Darlene
Sent: Wednesday, August 19, 2020 9:14 AM
To: 'billers@list.mnhomecare.org' <billers@list.mnhomecare.org>
Subject: PDGM vs non-PDGM

 

**External Sender**

 

Does anyone have a listing of which health plans are PDGM and which are not?

There may also be a difference between if they are a medicare advantage plan or someone on MSHO. I can’t get a straight answer from some of the health plans; I don’t know if they know what they are.

Thanks

 

Darlene Tuma, RN, PHN

Adult Health Supervisor

Le Sueur County Public Health

88 South Park Ave

Le Center, MN 56057

507-357-8249

Fax:  507-357-4223

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