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Wisconsin Medicaid PDPM: Post-implementation analysis

Jun 20, 2022
By: Terri Lee

Here we are several months into billing under the new requirements for Wisconsin Medicaid Nursing Home PDPM Acuity Specific Billing for room and board. Let’s look at how the transition has gone with an implementation check for this updated patient-driven payment model. 

We’ve included some troubleshooting tips for unpaid claims or unresolved balances, and some billing guidance and best practices to carry us forward in this new billing environment.

Transition implementation check

We’ve heard from providers that the transition went well, for the most part, with a few exceptions. We’ve worked one on one with providers and resolved payment holdups. Some of the challenges we faced include:  

  • Some clearinghouses had issues with the changes — rules/exceptions needed to be added.
  • The Assessment Indicator (AI) of 6 created some challenges with AR software and clearinghouses.
    Note: AI of 6 for the OBRA Assessment was the direction we received from the state of Wisconsin. The challenge was CMS no longer recognized this AI. For clarification, on March 3, 2022, Myers and Stauffer LC released Version 2 of the Nursing Home PDPM Acuity Specific Billing Guidance that specifically lists the Assessment Indicator of 6: OBRA Assessment. See version 2 of the guidance here.
  • Ventilator billing was not mentioned in the communications. Claims should include the 0022/PDPM code in addition to the 0946 ancillary code.
  • AR software transitions had a few hiccups. Those have been resolved or we’ve figured out workarounds.
  • Medicaid coinsurance crossover claims for Part A stalled with the early runs. The department was notified and those resolved by the time February 2022 claim crossovers hit.
  • Managed care organizations (Family Care plans): Contacts for communication and clarification on billing guidance were missed, resulting in unpaid claims.
  • Dual eligible plans (not Family Care): Contract wording of “follow Medicaid” vs. specific listing of revenue codes for the Medicaid portion of the plan determines if billing requirements changed. If not in contract, information updates on the payer website may have been missed.
  • 30-day mandate: These are paying PDPM like Medicaid, and you will need to send your rate sheet in with claims.

Troubleshooting tips

What do you do, and where can you turn if the transition has not gone well?

Provider payments do not match outstanding AR balance

  • If it’s widespread, has the rate information been setup correctly in your AR software?
  • Is the patient liability correct?
  • Does the PDPM score billed by date of service match the AR software PDPM score and date of service?
  • If it’s hospice, is your software setup at the correct amount from your January 2022 rate letter and percentage per contract? Was revenue code 0169 billed?

Managed care organization (Family Care) not processing claims

  • Check for provider communications and contract updates on claim process and billing requirements. Updates for most were sent out in December 2021 outlining revenue codes and process for updating the PDPM scores and authorizations and can usually be found on the provider portal website.
  • Many updated the authorization numbers effective January 2022. Was the correct authorization billed?
  • Was a new authorization obtained when a HIPPS code changed on the MDS?
  • Contact the MCO directly to analyze why payment is not received. Ask for written guidance on any claim changes/releases.
  • If billing through a clearinghouse, did your claim pass all edits and make it to the payer?
  • If it’s a Dual Eligible Plan (not Family Care), was there any change or update to the contract or information on the payer website? Establish and document conversations with customer service representatives and escalate as necessary.

Billing claim submission guide and best practice checklist

Some providers have adopted a Medicaid claims review process prior to claims release similar to the Medicare triple-check review process. Below are some items to review for accurate claims submission.

  • Obtain the MDS Assessment History Report: Each software program has some version of this report. Use this report to communicate with the MDS team and identify any completed or pending assessments for the current billing period.
  • Mark any claims that have incomplete assessments to be held or partially billed until the open MDS can be completed. Validate that completed assessments have the correct dates billed with the new MDS HIPPS score.
  • Do a quarterly review: Now would be a good time to do a lookback of MDS’ from January 1, 2022, through March 31, 2022. Were the correct HIPPS codes billed? Were there any MDS corrections or modifications to previous MDS’ that will require claim adjustments from previous months?
  • Adjust any claims identified that were billed with incorrect information. The general rule for timely filing is one year from the date of service.

Sample items to include on a Medicaid UB04 claims checklist

  • Form Locator 31-34 (optional) Occurrence Code 50 and the Assessment Reference Date (ARD) for all HIPPS included on the claim. ARD does not exceed 92 days from claim dates of service.
  • Form Locator 42 contains revenue code 0022.
  • Form Locator 44 contains the 5-digit HIPPS code from the current active MDS.
    Note: There may be multiple lines on a claim with the 0022-revenue code if there is more than one active assessment covering the from and through dates of service on the claim.
  • Form Locator 46 contains the number of service units per HIPPS code.
  • Form Locator 47 contains the usual & customary charge amount for the service units billed.
  • Service lines are listed in chronological order.
  • Form Locator 44 on the UB04 5-digit HIPPS code matches the active MDS assessment.
  • Diagnosis Codes match those from the active MDS: Admitting, primary, additional.
  • Validate any Default HIPSS of ZZZZZ are appropriate.

Wisconsin Medicaid PDPM: Post-implementation analysis

How Wipfli can help

Have you calculated your impact of the RUGs to PDPM transition? Maximum decrease payments for first quarter are set to be released in summer of 2022.

Our team at Wipfli is ready and willing to assist with any questions or concerns you may have related to billing and payment issues related to the PDPM Acuity transition. Contact us to learn more.

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Terri Lee
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