Home Healthcare Prior Authorization Services

The number of Home Health Agencies (HHA) grew by 40% between 2010 and 2020 driven by advances in technology, an aging population, rising healthcare costs and focus on patient-centric care. However, home care agencies and practices continue to remain burdened with the need for constant prior authorization (PA) and re-certification.

Not only do payers require Home Healthcare Practices (HHP) to obtain prior authorization for home health billing and to determine insurance eligibility, their eligibility requirements vary greatly.

As a leading home health care prior authorization company, we have helped practices flourish across the US. Let us look at how we help home health care practices overcome challenges and thrive.

Home Healthcare Prior Authorization and Related Challenges

Prior authorizations actually originated from the utilization review process in the 1960s, at the beginning of Medicare and Medicaid legislation. They were used to verify hospital admissions, by checking the need for treatment based on a confirmed diagnosis by two doctors.

Today, Medicaid and commercial insurance companies (BCBS, Humana, Aetna etc.) require home healthcare practices to obtain prior authorization before providing services. Without a

PA, practices cannot bill for services they provide and it is important to provide services in exact accordance with the PA received.

To obtain a pre-approval, you need to telephone the insurance company help desk. Service desk representatives typically provide a code or number that is associated with the authorization and that code/number will need to be added to the invoice (‘claim’) that you mail or electronically submit for home health billing

How Can We Help?

Transform your Revenue Cycle with our legendary support at just $7/hr.* (all inclusive) guaranteed locked-in rate till 2026!

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Home health care practices require prior authorization for various services that they provide, such as:

Skilled services: Nursing services like wound care and catheterization, occupational and physical therapy as well as speech-language pathology.

Unskilled services: Homemaker services, personal care such as assistance with bathing, dressing, toileting, and transferring., social services and nutritional counseling.

Additional services: Medical equipment and supplies, hospice which involves palliative care, telehealth and chronic disease management.

Common Home Care Specific Problems and Our Solutions

1. Administrative Burdens:

Complex and confusing regulations: Each payer has its own PA requirements, convoluted and subject to changes, making it difficult to stay compliant.

NAHC 2023 study: 96% of home health agencies faced prior authorization delays.

Solution: Excellent payer relations and years of experience working with all major payers has given us unique insights on managing pre-approval needs of home care practices.

Lengthy application processes: Filling out extensive forms with detailed clinical justification is time-consuming and diverts resources from patient care.

NAHC survey: 78% of agencies lack integrated software for PA submissions.

Solution: Our employees are adept at managing the specific PA requirement of HHAs. Outsourcing the prior authorization process frees up valuable in-house staff to take care of patient needs.

Frequent denials and appeals: Delays and denials due to incomplete paperwork, unclear criteria, or subjective payer interpretations lead to additional appeals and administrative work.

➢ Denials doubled for home health services between 2016 and 2020. (AAHCH analysis)

Solution: Our appeals process is second to none. We quickly communicate with payers, address and update forms, submit them and perform authorization follow up tenaciously until approval is received.

Staffing shortage & lack of in-house expertise: Advanced economies have been dealing with shortages of trained healthcare professionals and this problem is a major concern for the US healthcare system.

➢ 45% of respondents reported that staffing limitations caused delays in completing and submitting PA paperwork – National Association for Home Care & Hospice (NAHC) member survey.

Solution: Our Prior Authorization service for Home Healthcare Practices gives you access to a large and rapidly expanding pool of trained professionals. Our workforce is young, vibrant and eager. Engaging team activities and experienced managers keep employee morale high, leading to unmatched productivity.

High cost of managing PA teams: Rising minimum wage, employee benefits and federally mandated paid leaves have made it impractical for home health practices to hire, train and retain dedicated PA professionals.

➢ AHCA survey: 40% of agencies report staff burnout due to PA workload.

Solution: With our teams located in South Asia, we offer one of the lowest FTE costs in the industry. We invest in hiring, training and re-training our employees, providing them with extensive training and resources (Advanced software and AI driven tools.)

2. Technology Hurdles:

Outdated infrastructure: Cost concerns have kept home care agencies from implementing automated processes or cutting-edge software that can significantly

improve the PA experience. Investing in high-cost systems may not be the ideal choice for most practices.

➢ Streamlining PA processes through technology can save home health agencies up to $50,000 per year per clinician

🔺 Solution: Outsourcing to our home healthcare prior authorization service instantly gives access to the latest technology without any upfront investment and without the learning curve and teething issues of setting up a new in-house process.

Lack of integration: Incompatibility between payer platforms and provider software creates data management challenges.

➢ Incompatibility between systems costs providers $8-12 per transaction.

Solution: Our experience in servicing both providers and payer (utilization reviews) means that our systems and processes seamlessly integrate with payer platforms and practice management systems. From home healthcare billing and coding to accounts receivable services, this seamless integration features in all our offerings.

3. Payer-Driven Issues:

Stringent criteria and narrow interpretations: Payers often impose strict eligibility requirements and may narrowly interpret medical necessity, leading to denials for essential services.

NAHC estimate: Agencies lose $5,000 per denied claim.

Solution: Our PA professionals and billing and coding experts have deep knowledge of payer requirements when it comes to home healthcare services. With documentation management systems and constant communication with all parties involved, establishing medical necessity is no longer a worry.

Focus on cost-containment over patient needs: Prioritization of cost reduction by payers can limit access to necessary care and complicate reimbursement.

Solution: Having worked for both payers and providers gave us unique insights in managing review strategies that insurance companies follow. We know the specific requirements (for example) that Medi-Cal or BCBSTX have based on State-level legislation.

Lack of communication and transparency: Lack of clarity on denials and appeal processes hinders timely resolution.

Solution: Our team provides tenacious PA support, continuous authorization follow ups and making efforts to hasten approvals.

Outsource Home Healthcare Prior Authorization Services

As specialists in prior authorization for home healthcare practices, we bring a long list of advantages for your practice. Some of those are:

  • Instant reduction of costs by up to 80%
  • Real-time eligibility checks & fast authorization
  • 100% PA submissions on the same day
  • Increase rate of completed requests by 1.5 – 2X
  • 100% HIPAA-HITECH compliance
  • Rapid claim status analysis in denial management
  • T-A-T less than 48 hours max.
  • Low service fees with no hidden cost
  • No binding contracts
  • Over 100’s of client references across the country
  • Real-time audits and custom reporting

Schedule a no-obligation call with our representative today to find out about what makes us uniquely suited to fulfill your PA needs

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