What is PDGM and why does it matter for billing?

PDGM (Patient-Driven Groupings Model) replaced PPS for home health in 2020. It divides episodes into 30-day periods classified by referral source, timing, clinical grouping, and functional level. Incorrect PDGM classification directly reduces reimbursement — often without a denial, just a lower payment.

Do you integrate with HHAeXchange?

Yes. We integrate directly with HHAeXchange for EVV data validation and billing. We also support Netsmart/Tellus for agencies in the Florida fee-for-service delivery system.

What is the difference between community care and institutional home health billing?

Community care uses professional claims (CMS-1500) for HHA and PCA services billed by visit. Institutional home health uses UB-04 claims under PDGM for certified skilled nursing and therapy episodes. Both run through our platform under separate billing tracks.

How do you handle Florida Medicaid managed care billing?

We bill all active Florida Medicaid MMC plans including Sunshine Health, Humana Medicaid, Molina Healthcare, and Simply Healthcare. We maintain current fee schedules and payer-specific rules for each plan.

Home Health

Home Health Billing.
Florida specialists.

Home health billing in Florida runs across two distinct tracks: institutional PDGM billing for certified agencies, and professional community care billing for HHA and PCA providers. Both require deep payer knowledge, EVV compliance, and HHAeXchange integration. We handle both.

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PDGM

Episode billing for certified agencies

EVV

HHAeXchange integration built-in

MMC

All Florida MCOs covered

Florida payers covered

MedicareFlorida Medicaid FFSSunshine HealthHumana MedicaidMolina HealthcareSimply Healthcare

"PDGM and community care billing for home health agencies across Florida."

What we handle for home health billing.

PDGM episode management and clinical grouping

OASIS submission, validation, and error correction

Community care professional billing (HHA, PCA)

HHAeXchange and Netsmart/Tellus EVV integration

Medicaid MMC billing — Sunshine, Humana, Molina, Simply

Florida AHCA compliance and audit support

RAP submission and final claim processing

Home health denial management and appeals

PDGM, OASIS, and the Florida-specific landmines

Home health billing in Florida runs on PDGM (Patient-Driven Groupings Model) for Medicare and on plan-specific fee schedules for Florida Medicaid MMC plans. The PDGM episodic structure rewards or punishes you across four classification dimensions per 30-day period — referral source, timing, clinical group, and functional level — and getting any of them wrong silently reduces the payment for the entire episode. Florida agencies most often miss on referral source (community vs institutional) because the order paperwork doesn't always make it clear. We verify referral source against the clinical record on every episode.

OASIS scoring drives clinical group assignment, and inconsistencies between OASIS and the rest of the chart trigger ADRs that delay payment 30–90 days. Our review cycle reconciles OASIS scoring against clinical notes before submission so the agency doesn't discover the gap on a downstream audit. RAP and NOA submissions are filed within the 5-day window or we explain why with documentation.

Florida Medicaid MMC home health — the parallel track

Florida Medicaid MMC plans (Sunshine, Humana, Simply, Molina) do not use PDGM. They use plan-specific fee schedules, prior-auth requirements, and visit limits that vary by plan and by service code. Agencies serving both Medicare and MMC populations need two separate billing tracks running in parallel — one PDGM, one plan-by-plan — and the practice management workflow has to keep them straight or denials cascade in the Medicaid track.

We maintain plan-by-plan rule libraries for every Florida MMC payer: prior-auth thresholds, units-per-day limits, allowed CPT/HCPCS combinations, modifiers required for skilled vs unskilled visits, and the timing rules around episode continuity when a patient transitions from Medicare to MMC mid-care. For HHA agencies serving the dual population, this is where 60–80% of revenue leakage hides.