Reimbursement Readiness

Business Tip for all types of wound practices. Hosted by Kathleen D. Schaum and Friends.

  1. JAN 22

    Ep.17 2026 OPPS Payment Changes for CTPs Will Not Happen “By Magic”

    As 2026 begins, Kathleen Schaum opens Episode 17 of Reimbursement Readiness: Business Tips for Wound Practice with a candid assessment of the turbulence wound care teams endured in 2025—particularly around cellular and tissue-based products (CTPs). While the 2026 Medicare Outpatient Prospective Payment System (OPPS) Final Rule brought meaningful improvements for hospital-owned outpatient provider-based departments (PBDs), Kathleen is still fielding urgent calls from departments that have not yet aligned their systems to capture those payments correctly. In this episode, Kathleen walks PBD leaders step-by-step through the critical operational refinements required to receive appropriate CTP reimbursement in 2026. She explains how unpackaged payment affects application codes, why charges must be adjusted, which legacy codes must be removed, and how flat-rate CTP product payment changes purchasing strategy. Kathleen also highlights the importance of updating formularies, charge description masters, EHR workflows, coding tools, and billing systems—emphasizing that improved reimbursement will not “happen by magic” without deliberate action. This episode serves as a practical readiness checklist for PBDs using CTPs today. If physicians or qualified healthcare professionals are applying CTPs in your department, this conversation helps you confirm what’s complete, identify what’s missing, and act quickly to avoid lost revenue in 2026. Download the Quick Guide

    15 min
  2. 12/11/2025

    Ep.14 2026 Home Health Payment Updates

    Kathleen welcomes Yesenia Banks to break down Medicare’s 2026 Final Rule for Home Health Agencies and DME suppliers, rounding out the series on year-ahead payment policy. Yesenia explains the Patient-Driven Groupings Model (PDGM)—how 30-day periods, admission source/timing, clinical groupings (including wounds), functional status, and comorbidity adjustments combine into case-mix weights and payment. She also clarifies LUPA thresholds, outlier scenarios, and why accurate, specific diagnosis coding remains essential to payment integrity. Turning to 2026 updates, Yesenia notes an overall 1.3% home health payment decrease—smaller than the larger cut originally proposed—and underscores that wound clinical groupings remain among the highest-paid. She details key exclusions from the 30-day PDGM bundle: DME NPWT devices and supplies are billed directly by the DME supplier, while disposable NPWT can be billed separately by the HHA on the same claim under the Better Wound Care at Home Act. Practical guidance helps teams hit visit thresholds, manage labor and supply costs, and protect margins despite recent year-over-year pressure on rates. Finally, Yesenia previews CMS’s move to restart the DMEPOS Competitive Bidding Program, including calculating winning bids at the 75th percentile, streamlined financial documentation, new product categories (CGM and insulin pumps; urological, ostomy, and tracheotomy supplies), and more frequent surveys/re-accreditations (at least every 12 months). The episode closes with links to CMS resources and learning materials so leaders can brief their teams, align documentation, and prepare workflows for January 2026.

    15 min
  3. 11/13/2025

    Ep.12 Payment: MPFS Final Ruling (2026)

    In Episode 12 of Reimbursement Readiness: Business Tips for Wound Practice, Kathleen Schaum unpacks the 2026 Medicare Physician Fee Schedule (MPFS) Final Rule—a document that determines how physicians and qualified healthcare professionals (QHPs) will be paid in the coming year. She explains how this 2,000-page rule shapes the final payment policies for services, procedures, and products, and highlights key changes across telehealth, surgical services, chronic care, and, most importantly, cellular and/or tissue-based products (CTPs) for skin wounds. Kathleen also clarifies the distinction between the MPFS and the final rule itself, showing how conversion factors and relative value units translate to real-world reimbursement rates. Listeners will gain a clear understanding of how 2026 payment updates affect both the application and product sides of CTP reimbursement. Kathleen explains why non-facility rates are increasing while facility rates are decreasing, and how CMS is introducing a single national allowable rate of $127.28 per square centimeter for most CTPs—with exceptions for BLA-approved and non-sheet products. She also emphasizes the importance of reviewing payer-specific coverage policies, reminding providers that a listed code or rate does not guarantee payment. The episode concludes with guidance on where to access the official Medicare links and an invitation to join Kathleen and Dr. Alton Johnson for a Wound Care Today USA Learning Live event covering CTP strategies for 2026.

    18 min

Ratings & Reviews

5
out of 5
2 Ratings

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Business Tip for all types of wound practices. Hosted by Kathleen D. Schaum and Friends.

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