Home health agencies under PDGM, OASIS, and continuous UPIC pressure.
The engagement
Corrected, defensible OASIS and PDGM scoring; an authorization and eligibility workflow that holds; pre-claim and ADR response packets built to the reviewer’s criteria; a Review Choice readiness posture; and a written read on dollars at risk versus dollars defensible per episode.
Week 1 — intake: episode and audit posture, Review Choice status, exposure. Weeks 2–4 — OASIS and documentation review against PDGM and the coverage rules, gaps flagged pre-bill. Ongoing — pre-claim review, coder and clinician coaching, and ADR / TPE response as demands arrive.
Regulatory context
Home health payment keeps tightening while review intensifies. The CY2026 final rule cuts aggregate payments a net 1.3% (−$220M), layering a permanent −1.023% PDGM behavioral adjustment onto the first installment of a larger temporary adjustment — so margin per episode is falling even as documentation demands rise. OASIS-E1 took effect January 1, 2025, with all-payer OASIS submission mandatory since July 1, 2025, expanding both the data captured and the surface auditors can test.
The Review Choice Demonstration — pre-claim review, post-payment review, or a 25% payment reduction — operates in Illinois, Ohio, Texas, North Carolina, Florida, and Oklahoma and was extended five more years. Underneath it all, insufficient documentation accounts for the majority of home health improper payments.
The throughline: in home health the assessment is the claim, and the claim is now reviewed both before and after it’s paid.
From revenue cycle through audit defense — each shaped to your operation.
The cross-cutting capabilities we bring to home health agencies:
Each service shaped to the specific pressure observed.
Three reasons home health agencies choose us:
We know OASIS the way contractors know OASIS. The integrity of the assessment is what the audit measures. We audit it the same way.
Startup through enterprise in one bench. First OASIS through 50,000-visit-per-year operation. Same methodology, scaled.
Defense built on the same evidence that earned the payment. Documentation works both directions — for the clinical picture and for the contractor.
Why does one OASIS item matter so much?
PDGM prices the whole 60-day episode off the OASIS and the diagnosis coding. A miscoded functional item or primary diagnosis can misprice the episode and, on review, convert it to a denial.
What is Review Choice, and does it apply to us?
A CMS demonstration in six states (IL, OH, TX, NC, FL, OK) where you choose pre-claim review, post-payment review, or a 25% payment cut. If you operate there, it shapes your entire billing workflow.
We’re failing ADRs — where do we start?
With a root-cause review of the OASIS, the face-to-face, and the homebound and skilled-need documentation — then a response system built to the contractor’s criteria so the next round closes.
Can you help before claims go out?
That’s our edge. Acta-augmented pre-claim review flags the gap to the coverage rules while the record can still be corrected — before the payer ever requests the file.
A moratorium is in place and providers are being suspended as outliers — are we exposed?
The moratorium affects new enrollments and ownership changes, not existing operations — but the same analytics that drive it drive payment suspensions for outlier billing. We read your profile the way CMS does and fix the exposure before it is flagged.
Are you a law firm?
No. We’re expert consultants and licensed investigators who know the OASIS the way the contractor knows it. We work with your counsel — building the record their argument stands on — and can serve as testifying experts. Nothing here is legal advice.
Tell us what you are up against. Scoping memo in week one, before any meaningful commitment.