Post-Acute Intelligence
PDPM FY2026 Final Rule: Winners and Losers by Case Mix Group
CMS FY2026 SNF PPS distributes +3.0% market basket unevenly. NTA-heavy facilities and high cognitive impairment case mix capture above-average rate increases. Know your case mix position.
Phase 2 Minimum Staffing Enforcement Now Active — 3.48 HPRD Citations Issued
CMS Phase 2 staffing requirements carry citation authority. Facilities below 3.48 HPRD or 0.55 RN HPRD face survey deficiency findings. CASPER data review essential before next survey window.
PDGM Behavioral Adjustment: LUPA Rates Above 15% Trigger Elevated CMS Review
Low-utilization payment adjustments remain the most-audited billing pattern in home health. LUPA threshold varies by HIPPS code — agencies need monthly case-mix analysis to manage risk.
Telehealth Flexibilities Extended for HHAs — New Documentation Standards Apply
PHE-era extensions continue with updated requirements for virtual visits. Clear delineation of remote vs. in-person eligible services now required in clinical documentation.
GIP Documentation: "Pain Not Controlled" Alone Now Insufficient — OIG Active
General Inpatient hospice billing remains OIG's primary target. Explicit symptom burden documentation required. Generic phrases trigger automatic review under new audit protocols.
Hospice Audit Intensification: Long-Stay Patients Under Elevated Scrutiny
OIG focused on 6-month prognosis documentation for long-stay enrollees. Terminal certification clinical documentation standards tightening across all MAC jurisdictions.
HCBS Settings Rule: ALFs Documenting Person-Centered Planning Gaining Medicaid Referrals
Medicaid waiver expansions reshaping ALF competitive landscape. Facilities with compliant HCBS documentation capturing referral pipeline advantage in expansion states.
30-Day Readmission Window: PAC Settings That Outperform Create Hospital Referral Advantage
Readmission penalties affect referring hospitals across all PAC settings. SNFs and HHAs demonstrating lower readmission rates have measurable competitive advantage in hospital discharge planner relationships.