Home health care allows patients to receive care from the comfort of their homes. However, navigating the complex maze of billing requirements like coding, compliance, and documentation requirements among others can turn even the most efficient agency to face major loss in cash flow.  

Home healthcare is a crucial aspect of modern healthcare delivery. This is because patients, mostly elderly individuals, and those managing chronic conditions, prefer receiving medical care from the comfort of their homes. 

Even though these services cater to patients’ convenience and thus ensure quality care, the billing process is highly complex. This is due to the multiple regulatory requirements, strict documentation standards, stringent coding needs, and frequent payer updates. Any minute error in claim submission can lead agencies to face delayed reimbursements, claim denials, and revenue loss. For example, as per industry data, roughly 41% of healthcare leaders report that 1 in 10 claims are denied. Thus, it is necessary for practitioners to partner with specialized billing teams to ensure effective revenue cycle management. 

Definition of home health billing: What it encompasses  

Billing here refers to the process of claim submission and obtaining reimbursement for medical services provided to patients in their homes. Some common services include: 

• Medical social services 

• Home aide services 

• Physical therapy 

• Speech therapy 

• Occupational therapy 

3 key challenges of home healthcare billing  

While the billing process might sound very easy from a theoretical perspective, from a practical view it can be quite tough. Some of the key challenges include: 

PDGM billing complexity: 

The Patient-Driven Groupings Model (PDGM) guides how these healthcare practitioners receive their reimbursements. In simple terms, due to this model, the unit of payment from 60-day episodes of care has shifted to 30-day periods of care. This indicates the necessity for a faster documentation turnaround. Additionally, given that billing periods are shorter, it increases the administrative overload for practitioners. In a bigger picture, billing staff are required to verify patient eligibility, ensure coding accuracy and documentation, as well as comply with payer specific demands within a shorter period. This can lead to errors in claim submission, further causing delays and rejections.   

Documentation and compliance related risks: 

Another crucial challenge here is ensuring accurate and timely documentation of services rendered, pertaining to Face-to-Face (F2F) encounter requirements and the Outcome and Assessment Information Set (OASIS) requirements. 

Under current regulations: 

• A Face-to-Face encounter with a practitioner is required to certify the patient’s need for home health services. Missing such documentation can lead to denial. 

• OASIS documentation is also crucial for both regulatory compliances. Errors in the same, such as missing or inaccurate clinical information, wrong coding, or untimely claim submissions, can lead to inefficacy in cash flow. 

Home health coding errors  

Billing for these services can also be deemed challenging due to the stringent CPT and ICD-10 coding requirements. For example, the CPT code 99500 is used for home visits for prenatal monitoring and assessment; meaning when a registered visits patients’ residence for monitoring purposes during high-risk pregnancies. If a billing staff inaccurately assigns such codes after failing to identify the correct ones, then it will create discrepancies in billing forms, leading to delays or denials. Not only that these codes are also annually updated given the increasing diseases. This makes staying updated on these coding requirements much more difficult.  

For all these above-mentioned reasons, it is necessary for providers to partner with specialized billers who can help take up some of the administrative burden. This will enhance patient care and in the longer run ensure efficacy of the revenue cycle management through reduced errors in claim submission. 

How partnering with a specialized company can help matters 

Specialized billing companies offer various benefits to these practitioners. To begin with, they have certified coders who ensure the effective usage of ICD-10 and CPT codes. For example, many RCM solutions companies claim to have a 99% or higher accuracy rate in coding. Furthermore, they are also updated on payer-specific demands for documentation. They regularly refer to payer portals and go through regulatory brochures to identify such demands. This will allow such experts to meet face-to-face compliance necessities as well as OASIS documentation requirements effectively. This helps them to prove the medical necessity of the services rendered. For example, many RCM solutions companies claim to have over 97% first-pass acceptance rate for medical claims.  

Which one is more effective? 

Outsourcing experienced billers allows practitioners to access expert professionals without facing the hurdles of managing an internal team. For example, RCM solutions companies like SunKnowledge offer their services at less than half the prices of what the in-house billing team charge, often priced around $7/hr. This indicates that outsourcing reduces the overhead costs of maintaining an in-house team. Not only that, given the staff shortage in medical billing with 40% turnover rate, practitioners can face immense issues to keep up with the administrative work of billing. RCM solution companies offer 10% buffer resources at all times, which in the bigger picture helps ensure effective billing workflow. 

Streamline your home health revenue cycle management with the right help  

Having effective billing measures in place is one of the most significant aspects of running a successful home healthcare agency. However, the process of billing can be quite complex, including regulatory compliance with coding requirements. Thus, a partnership with a specialized billing expert specifically outsourcing one allows these agencies to reduce administrative stress and maintain a healthy revenue cycle. 

If you are struggling to find the right billing strategy for your practice, then consider outsourcing a team of experts.