Home health billing is getting more complex every day. This complexity not only puts a strain on existing staff, it also requires that leadership constantly adjust strategy to keep the most talented professionals and prioritize education through ongoing training.
Many organizations have decided that it’s just too much work, instead outsourcing home health coding and billing to home health billing companies. But should you do the same? Our belief is that the choice is highly specific to your organization, but that still, every organization should consider working with outsourcing. The challenge is in looking for hints to determine whether you’re a good candidate. This is why we’ve put together the following signs – indications that it’s time for you to consider outsourcing your home health billing and that you’ll likely see short term benefits from working with a competent outsourcing partner.
An Environment of Complexity
First though, consider the recent changes.
The Bipartisan Budget Act of 2018 took on home health payment reform and became effective on January 1, 2020. This act eliminated the use of therapy thresholds for case-mix adjustment. Its provisions resulted in the Patient-Driven Groupings Model (PDGM). This removes payment incentives to overprovide therapy, focusing instead on clinical characteristics and other patient information.
Additionally, in March 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act allowed nurse practitioners, clinical nurse specialists, and physician assistants to certify and order home health services. For many organizations, this expanded the number of practitioners and complicated their billing, since these practitioners could now review plans of care and even supervise provision of services and items for patients who were beneficiaries under the Medicare home health benefit. The CARES Act also opened the door to telecommunication for home health services during the COVID-19 public health emergency .
The Choose Home Care Act, introduced in July 2021, is also positioned to further complicate billing for senior care.
Signs You Should Start Researching Home Health Billing Companies
But smart leaders are looking for signs that a changing billing environment is time to do something different. Here are five signs we believe mean that it’s time to start looking into home health coding companies and rethink your staffing and outsourcing strategies.
PDGM Is a Problem
We mentioned PDGM earlier because for many organizations, it can be an issue. It’s been the biggest change to home health coding in over 20 years, pushing many organizations to rethink how they approach home health billing. This is because, starting in January of 2020, home health agencies began being paid under a standardized, national 30-day period payment rate, if a period of care meets a certain threshold. Additionally, this rate is adjusted for geographic differences in wages and case-mix. Any 30-day period of care that doesn’t meet that threshold is reimbursed at a per-visit payment rate. A special outlier provision also exists to ensure appropriate payment for beneficiaries that have highly expensive care needs.
While some home health organizations have adjusted well, others are still struggling to properly adjust their billing practices to fit these new requirements. If you’re this far into PDGM and still struggling, it might be time to start researching home health coding and billing companies.
Your KPIs Are Off
For example, maybe you’ve noticed bad debt inflating, or maybe you’ve seen A/R as a percentage of billed A/R rising past comfortable levels. Maybe your net days in accounts receivable is creeping upward. Or maybe you’re seeing denial rates skyrocket.
If you’ve noticed anything off in these metrics, it’s likely time to start looking at root causes. For example, if claims are getting denied or underpaid because you aren’t billing properly, it’s likely time to take action. Are your billers confused or frustrated? Was your last training session not sufficient? Are they lacking training altogether? If any of these are true, it might be time to consider outsourcing your home health billing.
Case Mix Adjustment Has Been Confusing
Ideally, when adjusting billing to meet a Medicare beneficiary’s needs and condition, here’s what should happen according to CMS. After a doctor or allowed practitioner has prescribed a home health plan, you then assess the patient’s condition to determine whether they need therapy, medical social services, skilled nursing care, etc. This is done at the beginning of the 30-day certification period and for each following 60-day certification. The Outcome and Assessment Information Set (OASIS) instrument is used to assess the patient’s condition, using certain items to describe this condition along with other information that’s reported on a Medicare claim to determine the case-mix adjustment to the standardized 30-day payment rule. These 30-day periods are broken into 432 case-mix groups to adjust payments under the PDGM .
If you’re finding that your staff is struggling with this process or if reimbursement isn’t where it should be, it might be time to start working with a partner who understands case-mix adjustment and can support proper documentation on Medicare claims.
Outliers Are Giving You a Headache
If outlier payments are causing you problems, it might be time to start looking into home health coding companies that can also help you with billing.
Before the end of 2019, home health agencies received an outlier payment for episodes where costs exceeded the threshold for each case mix group. But after January 1, 2020, HHAs received an outlier payment for a 30-day period where estimated cost exceeds the threshold for each case mix group. The cost for each claim is determined by CMS by multiplying the national per-15 minute unit amount of each discipline by the number of units in the discipline, computing the total imputed cost for all disciplines .
If you’ve noticed your billers and coders having issues since the beginning of 2020 and not being able to recover by now, it’s likely past time to start working with a home health billing company.
Consolidated Billing is a Challenge
For some patients under a home health plan of care, a payment for services is consolidated under the HH PPS base payment rate. This happens when services (therapy, home health aides and medical social services, and nursing) and non-routine and routine medical supplies (except DME, certain injectable osteoporosis drugs, and furnishing negative pressure wound therapy using a disposable device) are consolidated. It is your responsibility to bill for these, but if you’re finding you’re having challenges or improperly consolidating these services, it might be time to rethink your outsourced billing strategy.
It can be difficult to determine which home health billing company you should work with, but we invite you to start a conversation with us as you determine your next step toward better billing this year.
 U.S. Centers for Medicare & Medicaid Services, “Home Health PPS,” 12 December 2021. Available: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS.
 Office of the Federal Register, National Archives and Records Administration, “42 CFR § 484.240 – Outlier payments.,” Government. Office of the Federal Register, National Archives and Records Administration, 1 October 2019. Available: https://www.govinfo.gov/app/details/CFR-2019-title42-vol5/CFR-2019-title42-vol5-sec484-240.