Managing Home Health Margins Through Clinical Quality

CMS is also proposing the addition of four measures to the applicable measure set. This includes three OASIS-based measures related to bathing and dressing, and one claims-based measure, the Medicare Spending per Beneficiary for the Post-Acute Care (PAC) setting measure. 

Due to the changes to the Model's applicable measure set, CMS is proposing to alter the current weights of individual measures and measure categories. 

Additionally, CMS is proposing to add and codify an additional measure removal factor at  § 484.358, Factor 9: It is not feasible to implement the measure specifications. 

HHVBP Quality Measure Concepts Under Consideration for Future Years - Request for Information (RFI)

CMS is including in the proposed rule an RFI that would build on input from the expanded HHVBP Model's Implementation and Monitoring technical expert panel (TEP). We are specifically asking for feedback about the addition of the respecified Falls with Major Injury measure as well as two potential changes to the HHCAHPS survey-based measures scoring rules and applicable measure set as they relate to the expanded HHVBP Model. 

Session 2 - Payment Changes: What to Expect for Medicare Home Health Payments in 2026

One of the biggest parts of this rule is the expected Medicare Home Health payment cut in 2026. CMS is projecting a total decrease in payments to home health agencies by about 6.4% compared to 2025. This means agencies will likely receive less money overall. 

Here's how the changes break down:

• There will be a 2.4% increase in some payment updates. 
• But this will be outweighed by a 3.7% cut related to behavioral adjustments aimed at correcting past over payments. 
• An additional temporary cut of 4.6% will start clawing back estimated over payments. 
• Finally, smaller cuts come from changes in how much they pay for very expensive cases (called outliers). 

Bottom Line for RCM Leadership: The CY 2026 proposed home health rule signals a convergence of financial pressure, operational complexity, and quality realignment. RCM teams must quickly model impact, optimize coding and documentation systems, recalibrate quality and value-based strategies, and advocate wisely as CMS finalizes the rule later this year. 

• Tighten coding/OASIS accuracy to optimize case-mix appropriateness. 
• Leverage tech to streamline documentation and support efficiencies

Steps to Manage Home Health Margins through Clinical Quality: 

• Audit PDGM Coding and Visit Plans - Ensure diagnosis coding and comorbidity capture are detailed and accurate to protect revenue. Review visit plans carefully to avoid unintentional LUPA penalties due to new thresholds. 
• Update Face-to-Face and Order Workflows - Adjust documentation templates for the expanded list of practitioners now allowed for F2F visits. Track any F2F issues as a key metric for avoiding denials. 
• Protect Quality Reporting Data - Treat QRP submission deadlines like payroll, don't miss them. Prepare early for digital reporting transitions (dQM and FHIR) by testing your data systems. 
• Train Staff on New HHVBP Measures - Educate clinicians on new cost-based indicators, and OASIS functional items related to bathing and dressing. Improve processes to manage spending efficiency to improve Medicare Spending Per Beneficiary - Post-Acute Care (MSPB-PAC) 
• Strengthen Denial and Audit Defenses - Be ready for more reviews from Medicare auditors focusing on behavioral payment adjustments. Keep documentation strong and organized support every claim. 
• Manage Labor and Visit Scheduling Closely - Align visit schedules with the new case-mix recalibration and LUPA thresholds. Use alerts to avoid plans drifting into under - visits situations.
• Additional operational adjustments 

Featured Speakers

Arnie Cisneros 

Arnie is the President of Home Health Strategic Management (HHSM). He has over 30 years of experience as a physical therapist across the care continuum, and he serves as a Post-Acute Consultant for multiple Pioneer Accountable Care Organizations (ACOs). He is renowned for his adaptation of traditional health care operations to address onhoing Centers for Medicare & Medicaid Services (CMS) reforms. 

Kimberly McCormick 

Kimberly is a highly accomplished nurse consultant in home health. She is the Executive Clinical Director for Home Health Strategic Management. With 24 years of experience in home health, including nearly a decade as the administrator of a home health agency, Kimberly has the experience and knowledge to provide unrivaled insight into the home health arena. Kimberly previously served as an Associate Consultant with HHSM, where she has established herself as an expert in the utilization management of home health services. 

Registration 

Full Series 

Member - $120

Non-member - $240

Single Session  

Member - $50

Non-member - $100