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PDPM case-mix per diem

Use PDPM case-mix per diem when reimbursement is based on PDPM case-mix payment amounts for covered skilled nursing facility days. You can use this model for either of these financial relationships:

  • A payor reimburses a billing provider for therapy services.
  • A facility reimburses your therapy organization for selected components of its PDPM payment under a contract.

Before you start​

For a payor reimbursement arrangement, create the payor with PDPM case-mix per diem selected as its payment model. A payor's payment model cannot be changed after the payor is created.

For a facility contract, the contract payment model is configured separately, but it can apply only to payors using PDPM case-mix per diem.

Set up a payor reimbursement arrangement​

  1. Open the payor.
  2. Click Reimbursement arrangements.
  3. Click New reimbursement arrangement.
  4. Enter the arrangement period and choose the billing providers it applies to.
  5. Under Payment details, choose whether to include the wage index adjustment.
  6. Choose whether to include the variable per diem adjustment for PT, OT, and NTA.
  7. Click Save.

Set up a facility contract payment term​

  1. Open the facility.
  2. Click Contracts.
  3. Click New contract.
  4. Enter the contract dates and add a contract payment term.
  5. In Step 1: Choose how the facility pays [your organization name], select Contract payment model, and then select PDPM case-mix per diem.
  6. In Step 2: Choose payors, choose all eligible payors or filter by payor type or specific payors. Only payors using PDPM case-mix per diem are eligible.
  7. In Step 3: Configure the contract payment model, choose whether to include the wage index and variable per diem adjustments.
  8. For each PDPM component, enter the therapy organization revenue-share percentage and select its normal day and discharge-day rules.
  9. Click Save.

RehabAlpha calculates the selected PDPM component amounts for each eligible day, applies the chosen adjustments, and then applies each component's revenue-share percentage. The contract term uses its own settings; it does not use the payor reimbursement arrangement's adjustment settings.

For either workflow, add billing episodes with the skilled nursing facility service location, initial stay day, and initial benefit day needed for PDPM case-mix per-diem billing.