Let’s talk LUPAs—because even a 5% LUPA rate could be costing your agency more than you realize. Under PDGM, when a 30-day payment period falls below the visit threshold, Medicare applies a Low Utilization Payment Adjustment (LUPA). That payment can be 40–60% lower than the full episodic rate. It adds up fast. Here’s the math:If…
Let’s talk LUPAs—because even a 5% LUPA rate could be costing your agency more than you realize.
Under PDGM, when a 30-day payment period falls below the visit threshold, Medicare applies a Low Utilization Payment Adjustment (LUPA). That payment can be 40–60% lower than the full episodic rate. It adds up fast.
Here’s the math:
If you’re running 300 payment periods a month, a 5% LUPA rate = 15 LUPAs/month. That could mean $6,000–$12,000/month in lost revenue—or more than $70,000 a year walking out the door.
And that’s just at 5%. If you’re pushing 10% or higher, you’re looking at six figures in lost revenue.
What’s driving it?
- Incomplete care planning at SOC
- Visit delays from staffing shortages
- Gaps between clinical and scheduling teams
- Diagnoses or documentation that understate the patient’s true needs
What to do about it:
- Start tracking LUPAs by clinician, diagnosis, and payer—you’ll spot patterns quickly
- Use case conference time to flag at-risk episodes early
- Set internal goals: keep LUPAs below 5%
- Train your team to plan visits proactively and document skilled need clearly
Bottom line: LUPAs aren’t just billing issues—they’re operational red flags. And they’re absolutely fixable with the right data and team alignment.
