PDGM period and per-diem revenue, reconciled for home health and hospice
Our AI agents reconcile every 30-day PDGM period and every hospice per-diem day to the record behind it: assessment, visits, level of care, payments. Our experts set the rules and take the exceptions.
The eight period and per-diem workflows, in the order we would automate them
- 30-day period ledger reconciliationIn the top ten of 169 workflowsWorth it, ready now
- Assessment-to-payment accuracy auditIn the top 25 of 169 workflowsWorth it, ready now
- Hospice day-and-level reconciliationIn the top 25 of 169 workflowsWorth it, ready now
- Aggregate cap and inpatient-day limit projectionIn the top half of 169 workflowsWorth it, ready now
- Verified-visit-to-claim reconciliationIn the top half of 169 workflowsWorth it, ready now
- Room and board pass-through reconciliation for nursing facility hospice residentsIn the top half of 169 workflows
- Margin by period, level of care, payer and branchIn the lower half of 169 workflows
Tell us where your agency would start here; our experts bring the ranking and your numbers.
Talk about one workflow
Periods and days bill below what they earned, unseen until close
Home health periods and hospice per-diem days leak payment between the assessment, the visit and the claim.
Periods billed short
Assessment, schedule, claims sit in different screens; case-mix bills under visits earned.
Levels corrected at audit
Hospice days bill from the schedule; the level gets corrected only when the auditor finds it.
Costs never tied to days
Pharmacy and supply invoices paid as received; per-diem absorbs them without patients.
Daily period and per-diem record checks
Each workflow below joins the records behind your periods and days, and queues what does not match.
Every 30-day period reconciled before it bills short
Periods fall to a per-visit payment one visit short of the threshold, and nobody sees it until the claim is paid. Our AI agents queue each case-mix shortfall with the record attached; our experts set the rules.
- Every period bills at the case-mix earned
- Shortfall and threshold queue lands daily, record attached
- Unbilled and partial periods surface before month close
Assessment by assessment, payment accuracy audited
The coding vendor samples quarterly, so a score that outruns the nursing narrative sits in the payment for months. Our AI agents check assessments for consistency against clinician and branch distributions; our experts review the outliers.
- Scoring covers the full assessment set
- Outliers flagged in both directions, by clinician
- Case-mix distribution visible by clinician and branch
Every hospice day billed at the level the record supports
Days bill from the schedule; level of care is corrected at audit, the add-on by chance. Our AI agents reconcile every day to the visit record and benefit history, hold unsupported levels; our experts take what they flag.
- Unsupported levels held before the claim
- Continuous care hours billed as earned, record attached
- Every day matched to visit record and location
We watch the workflow before anything is built
Your agency brings the systems it already has: EMR, clearinghouse and payer portals, plus the team that lives this work. Nothing is replaced.
01What your agency brings
Your EMR, your clearinghouse, your payer portals, and the people who know the periods and the days. Nothing is swapped out.
02What our experts do
Our engineers and revenue-cycle specialists sit with your billing and clinical teams, map the workflow as it runs, fix the data, and set the rules.
03What our AI agents do
Our AI agents join the assessment, the visits, the levels and the payments into one ledger, and queue shortfalls and unsupported days daily.
The alternatives hold the period data; none reconciles it
Most agencies run one of three: billing and RCM software, the EMR's own billing module, or an outsourced billing company. Here is where each stops.
Custom AI built inside your revenue cycle
Our experts set the rules for your payers and your periods, and our AI agents run them inside your operation, beside your EMR. We start with the workflow where you lose most.
- Every period and day reconciled to its record
- Rules written for your payers, changeable by staff
- First workflow is where you lose most
Billing and RCM software
Good at holding claim data in one place; it typically runs the same steps for every agency, so short periods stay short.*
Your EMR's billing module
Good at staying connected to the chart; it usually covers the standard path, so day-and-level checks ride on workarounds.*
An outsourced billing company
Good at taking the pile off your desk, usually per claim; the periods and days then move to their queue.*
* Each category is described as it is commonly sold; what any one vendor's product covers varies by seller.
Your EMR stays, your staff decide, and pricing is per workflow
Does our EMR stay?
Yes. Your EMR, clearinghouse and payer portals all stay, and your data stays yours; the agents work beside them.
How is it priced?
A base fee plus a share tied to results; which workflows our AI agents run for you sets the price, however many people log in.
Who makes the calls?
Your staff do. Our AI agents check and flag; your team reviews and decides, and no software makes a clinical call.
What must we have ready?
Just the records your team already touches: recent claims, assessments and census. Our experts bring everything else.
Every period and every per-diem day reconciled before it bills
Ask for a conversation about one workflow. Our experts walk the cost with you, name what our AI agents would take over, and you choose what is built first.
Common questions
How is the hospice cap calculated?
The hospice aggregate cap is apportioned proportionally across hospices that shared a beneficiary's care. Our AI agents project it monthly from your census and payments to date.
What are the CMS billing guidelines for hospice services?
Hospice drugs, supplies, appliances and equipment are covered when related to palliation of the terminal illness, per the plan of care. Unrelated items bill outside the benefit.
What are the documentation requirements for hospice general inpatient care (GIP)?
A general inpatient day is billed at the level and site the record supports: visit record, location, election and benefit history. Our AI agents reconcile every day to those records.
What is the limit for a hospice respite inpatient day?
Respite days count toward the hospice inpatient-day limit that feeds the aggregate cap, apportioned across hospices that shared a beneficiary. Our AI agents project that limit monthly.
Who pays for room and board in hospice?
For hospice residents in a nursing facility, the state Medicaid program pays room and board, passed through the hospice to the facility. Our AI agents match the payment, invoice and days.
Why do some hospice organizations pay a per diem rate for medical supplies?
Because the per diem is meant to cover them: hospice drugs, supplies and equipment are covered when related to palliation of the terminal illness; unrelated items bill outside the benefit.
The full study, PDF · 636 KB
Start with the cash file, not the biggest problem
The most depended-on workflow in the study is a middling performer on paper. Do it first anyway.