Home Health Billing Basics: What You Need to Know to Get Paid

Struggling with the complexities of home health care revenue cycle management?  

This blog covers the basics of home health revenue cycle management (billing) so you can start getting paid for your valuable services. 

As a business owner, it’s important that you have an organized system in place to make sure everything runs smoothly when getting paid by payers like Medicare, Medicare Advantage, or private insurance companies. 

This will help ensure that payments go through without any hiccups which may lead to delays with accessing funds. If you’re already in need of advanced funding to jump start your cash flow, check out our Advanced Funding and Line of Credit programs. 

Here are the steps we’re going to cover in this blog: 

1. Identifying who is involved in the billing process 
2. The role of the payer 
3. How to get started in home health billing 
4. Tips for keeping organized and getting paid 
5. The Importance of follow up

Let’s get started. 

What You Need to Know about Billing

In home health billing, there are many different people involved in the payment process. It is important to know who these players are and what their role is so you can get paid for your work.  

Who Does It Involve?  

To start with, there’s the patient. 

All the tasks completed by all involved serve the patient (or should). 

The home health agency is the next player. 

Agencies employ skilled and/or unskilled individuals who make visits and complete documentation on the patient. 

These individuals could be nurses, physical therapists, occupational therapists, speech therapists, social workers, or other types of caretakers. 

Payers are the third party, and are either Medicare, Medicaid, and/or other insurance companies.  

What Role Does the Payer Have?  

There’s an old saying. 

If you want to learn how something works, always follow the money!

Well, in the case of home health billing, this adage proves to be 100% true. 

Let’s talk about the cash flow for a moment. The goal of cash flow is to create predictable revenue. 

Payers receive bills (also called claims) from the agencies and send out payments for covered services. 

In order to receive payment for a claim, an agency must be sure to abide by the rules set out by the payer. 

Each payer can specify its own set of rules and processes for claim submissions. 

Agencies can contract with specific insurance payers, and collecting payments from them can be frustrating. 

Where Does Insurance Come into Play?  

Insurance isn’t always an easy thing to figure out. 

So let’s talk about contracts.

A contract is a written agreement between a particular insurance company and a home health agency that outlines the covered services and the rates for which those services are covered. It also gives important information the agency needs on how to receive payments.

Contracts can vary, even within an insurance agency. 

In other words, just because two agencies are set up with the same payer, it doesn’t mean that their processes are the same.  

Payers are not all created equal. 

Some have excellent customer service departments and are helpful, while others are difficult to work with and seem to do everything within their power to NOT pay a claim. 

It’s important to determine whether or not authorization is required from the insurance company prior to servicing a patient. 

Note:

Some insurances require authorization, sometimes referred to as “prior approval” which is a decision by the insurance company that the treatment or care is medically necessary. It does not necessarily guarantee payment.

Verifying with the payer if the authorization is ‘discipline specific’ is also an important part of the process of obtaining an authorization.

If an agency isn’t contracted with an insurance company and sees a patient, that patient is considered out of network. 

Reimbursement would then be based on the out-of-network benefits. 

That agency would then need to contact the insurance company in hopes of getting the claim paid. 

Many agencies choose not to admit patients unless they’re insured with a contracted payer. 

Doing an eligibility check for the patient is an important part of the admission process. Here’s how to get started.

How to Bill for Home Health Care

The first step in home health billing is to discover if you can receive payments for your client. You need to get approved to receive payments from your client’s payer. Ex. Medicare, Medicaid, insurance companies, etc.

After becoming approved to receive payments, you will then begin the process of sending claims to the payers.  Remember, claims are what you send to payers to bill for home health services rendered.

How do you bill home health claims?

Claims are sent to payers via an EMR/EHR. An EMR (electronic medical record) is software that keeps the patient’s medical record. 

When an agency is under contract with an insurance company, Medicaid, or Medicare, the agency will receive specific guidance to set up the necessary information within the software.

This billing information may include:

• Claim type
• Revenue codes, and 
• Which types of forms to submit to allow a bill or claim to be sent out of the EMR

Keeping track of sending claims and receiving payments is known as revenue cycle management (RCM.)

Here are a few ways to help you keep track of your billing and payments.

Tips for Keeping Things Organized and on Track

Every agency is unique, and there’s no ‘one size fits all’ formula for creating processes for billing workflow. 

But there are some best practices that you should know and understand.

1. Use a “clearinghouse” for claim and payment tracking  
2. Explore billing and Coding partners for your agency.

1. What is a Clearinghouse?

A clearinghouse is a hub that connects the claims to all of their respective payer portals. 

While agencies could log into each payer portal individually, a clearinghouse makes these transactions (and the follow up) easier on the biller. 

Most clearinghouses also offer some type of analytics on things like: 

• What’s been paid
• What’s been denied
• Other statistics to help filers to monitor claims and payments 

Clearinghouses can also “scrub” a claim to check for errors before it’s sent. 

This helps to reduce rejections and lowers turn-around time. 

Clearinghouses can also allow you to manage claim denials, or engage in the appeal process for individual claims. 

2. Billing and Coding Partners

Some agencies choose to hire a biller to complete documentation in-house, while others hire outside billing companies. Hiring an outside company to complete the service is known as “outsourcing.”

What Are Some of the Benefits of Working with a Professional Biller? 

Outsourcing allows you to tap into the knowledge of home health billing experts. 

Outsourcing can also help you to better manage the billing for your agency, allowing you to concentrate on patient care while leveraging the RCM partner’s talents and expertise. 

Additionally, imagine that your in-house biller becomes sick, goes on vacation, or takes another position. 

In that case, billing could get behind. 

Taking the time to hire someone else may cause your agency to miss out on revenue. 

An outsourcing company, however, likely has multiple billers who know the same account.

For these reasons, outsourcing medical billing has become a popular approach. It also boasts other benefits. For example, it frequently: 

• Lowers administrative costs
• Promotes consistent coding and billing procedures
• Enhances compliance, and 
• Boosts productivity 

You’ll want to be sure that any outsourcing service is able to provide you with routine updates on what has been billed and what has been collected. 

And as always, communication with the outsourcing service is key. 

The Importance of Follow Up

Ultimately, it’s the biller’s job to follow up with a payer to see if a claim had errors, or if it’s processing as expected.  Billers have to be persistent! 

If things were electronically submitted and accepted according to the plan, the agency will receive a reimbursement check or EFT, along with an EOB (Explanation of benefits). 

The clearinghouse then communicates the ERA (Electronic Remittance Advice) or “remit” back to the EMR software, so that a biller can post the payments to the patient accounts. 

What to Do If the Claim Is Not Approved? 

If a claim is rejected, the biller must make the necessary changes or corrections and resubmit the claim.

Listen to this episode of Home Health Revealed to learn more about denials and appeals. 

Billers can expect to make many calls to insurance companies to follow-up on claims. 

Home health billers are involved in every step of the billing process, and are wise to form relationships with:

• Agencies
• Insurance companies
• EMR companies, and 
• Clearinghouses 

They must be excellent time managers and highly organized; agencies depend on them to keep revenue coming in.

In Conclusion

By understanding the billing process and what you need to do, home health care providers can get paid for their services. If your company is struggling with getting paid on time or having an accurate count of patient visits, please reach out to us today. 

Our team will help you streamline your billing practices so that you are able to stay in business while still getting every dollar owed. 

Frequently Asked Questions: 

How to bill Medicaid for home health care

Medicaid is state-specific. 

Some Medicaid Programs pay for care directly, while others use private insurance companies to provide coverage. 

It’s important for providers to verify coverage, and to bill only for those covered and completed services. 

Medical records must be up to date and accurate. 

How to bill Medicare for home health services

Medicare costs must be billed directly through Medicare.  

Providers must send the claim directly to Medicare, and then Medicare will reimburse directly to the service provider. 

The individual receiving the service will generally never see a bill from their provider.