How a Home Health Billing Company Can Help Prevent Common Claim Denials

Managing a home health agency (HHA) is no less than a challenge for providers. The reimbursement process is more complex than other specialties because the payment depends on various factors. These include patient’s eligibility, clinical status, plan of care, and regulatory requirements.

A home health service may can be clinically appropriate, but the associated claim may still be denied if the documentation is incorrect. In contrast to office-based services, home health billing is shaped by certification requirements, clinical assessment instruments, payment groupers, and episode-based timelines. A professional home health billing company can help you manage these complexities more efficiently. If you are not receiving reimbursement on time, there may be errors in the documentation or coding of your services. Let us examine the common issues that can prevent your insurance claims from being approved.

Reasons behind claim denials in home health billing:

Many providers struggle to receive reimbursement on time, despite their best efforts. Claim denials can significantly affect the home health revenue cycle and increase overall administrative costs. The major reasons behind these denials are:

1. Timeliness of NOA submission:

The Notice of Admission (NOA) timeline and proper establishment of the home health period of care are critical components of home health medical billing. The NOA records the beneficiary’s home health period of care in Medicare’s systems and supports the submission and processing of subsequent 30-day claims.

For instance: a patient admitted on May 13 had an NOA submitted on May 15. While the delay was only two days, the home health center could face a payment reduction for the affected period of care.

CMS requires the NOA to be filed within five calendar days of the start of care. A late submission can reduce payment and create issues with subsequent home health claims processing. NOA problems can also occur when the Medicare system does not properly establish the patient’s home health period of care. Common causes include incorrect beneficiary information, failure to submit the NOA, transfer-related errors, and incorrect provider information. An expert home health billing company confirms the start-of-care date, submits the NOAs as early as possible, reviews rejected NOAs and submits corrected NOAs.

2. Certification errors:

According to CMS policy, the face-to-face encounter must occur no more than 90 days before or 30 days after the start of care. The encounter must have findings that clearly establish homebound status and the need for skilled care. For each Medicare patient, a qualifying face-to-face (F2F) encounter must establish the need for home health services and support patient’s homebound status. An authorized practitioner must sign and date the encounter within the required 90-day period before or 30-day period after the start of care. When required certification elements or supporting documentation are incomplete or fail to satisfy Medicare standards, the associated home health claim may be denied. The following certification errors could be a common reason for claim denial in your practice:

• The required physician or practitioner’s certification is missing
• The certification or related plan of care lacks the required signature
• Continued home health services are not properly recertified when required
• The encounter was conducted, or the certification was completed by someone who does not meet Medicare’s applicable practitioner requirements
• The clinical note or other required documentation supporting the encounter is unavailable

While when you hire a professional home health billing company, you get the following verification benefits:

• The patient encounter is properly documented
• The certifying practitioner meets the applicable requirements
• Required signatures and dates are present
• The face-to-face encounter occurred within the applicable timeframe
• The plan of care is established and appropriately signed
• The certification supports the need for skilled services

3. OASIS errors:

It is important to note that OASIS-E2 data and claim data work together but are not interchangeable. Certain OASIS responses affect the functional impairment component, whereas the principal and secondary diagnoses reported on the claim determine clinical grouping and comorbidity adjustments. Some of the common OASIS-related errors in home health billing are:

• Incorrect assessment information
• Inconsistent OASIS responses
• Incorrect assessment timing
• Missing/incomplete OASIS information
• Incorrect functional-status responses

For example, a functional-status reporting error may first affect payment classification rather than result in an immediate claim denial. The agency may be subject to denial or recoupment if the payer later determines that the OASIS data, reported diagnoses, and clinical documentation do not substantiate the claim.

When you partner with an efficient home health billing company, you get benefits such as complete and accurate validation of OASIS, comparison of OASIS responses, and review of the functional impairment classification. The billing team also checks the comorbidity adjustment, verifies the appropriate PDGM clinical grouping, and uses the correct CMS grouper version for the applicable claim period.

4. PDGM errors:

We all know that under PDGM, Medicare mostly assigns each 30-day home health period to a case-mix payment group based on admission source, timing, clinical grouping, functional impairment level, and comorbidity adjustment. CMS states that a claim may be returned to the provider when the principal diagnosis does not map to a clinical group. CMS also applies grouper edits to identify diagnosis-coding issues that require correction. A frequent coding error occurs when a diagnosis is reported solely because it appears in the patient’s history, without adequate clinical support showing that it applies to the period being billed. Some of the common PDGM errors are:

• Unsupported secondary diagnoses
• Incorrect principal diagnosis
• Principal diagnosis not assigned to a clinical group
• Mismatch between OASIS and claim

An expert home health billing company verifies the correct admission source, diagnosis sequencing, early or late period designation, and consistency of OASIS information.

5. Delayed claim submission:

Timely filing requirements for home health claims vary by payer. Providers must adhere to each payer’s specified submission deadline to protect reimbursement and avoid claim denial. If your in-house billing team is submitting home health claims after the deadline, you are losing a significant portion of revenue. Claims may still be denied for untimely filing, even when the documentation is complete, and the coding is correct.

A home health billing company with several years of experience submits claims within the specified timeline. Their trained staff monitor filing deadlines, submit claims promptly, and follow up on rejected or denied claims to identify appropriate correction and resubmission options.

Why choose SunKnowledge as your preferred billing partner?

If you are looking to streamline your home health billing revenue cycle, SunKnowledge offers comprehensive solutions. With over 17 years of industry experience, we provide dedicated account managers at competitive costs. Home health reimbursement is more than just submitting claims. It involves accurate documentation, coding, and proper denial management. We have served leading healthcare providers, with numerous satisfied clients who can serve as references. Our accurate claim coding and preparation can help you achieve a first-pass submission rate of approximately 97%.

As a provider, maintaining a dedicated appointment scheduling team can be challenging. A home health billing company like SunKnowledge offers specialized virtual assistance for appointment scheduling and patient inquiries. Reach out to us if you are aiming for improved financial stability and better patient care. We have the skill and experience to transform some of the biggest billing challenges into revenue opportunities.