Home Health Billing
Home Healthcare Revenue Cycle Management
Home Health Care Qualification:
To be eligible for Home Healthcare, either: 1) patient’s condition must be expected to improve in a reasonable and generally predictable period, or 2) patient needs a skilled therapist to make a maintenance program safely and effectively for your condition, or 3) patient needs a skilled therapist to do maintenance therapy safely and effectively for your condition.
In-take Department:
Patient intake is the process through which healthcare organizations collect demographic, social and clinical data, consent forms, insurance, payments, and other key pieces of information from new and returning patients prior to their visit. The Intake Coordinator is responsible for the admission process for new patients by ensuring availability of reimbursement for services, identifying the clinical team to deliver care, and scheduling all patient visits within prescribed discipline and visit frequency requirements.
Collection of Orders and Referrals:
At the time of referral, the intake coordinator should collect the following documents before accepting the patient to their Home Health Agency.
• History and Physical with any recent office visit notes
• Home care order with face to face
• Reconciled Medication List
• Signing/ Primary physician for the patient and where orders should be sent.
• Patient Demographics
Patient’s real-time eligibility and benefits verification:
Once the demographics are collected, the insurance verification team will verify the eligibility and benefits to see if the patient is having an active coverage and home care visits are covered as per the patient’s plan benefits. Insurance verification are done with the payers by calls/payer online accounts. The following information are collected during the verification process:
· Patient’s current active policy with the payer
· Plan and group name
· Home Health benefits
· Patient cost-share liability, if applicable
· Prior authorization requirement for all Home Health disciplines
· Network status of Facility/Agency with the payer
Plotting of Clinicians and services:
Once the verification team confirms the patient’s eligibility and benefits information and after the required orders are collected by the intake team, the required home care disciplines for the patient are plotted with the respective clinicians, clinical nurse, therapists, MSW, and Home Health Aide. The start of care is plotted as per the request from the patient.
Prior authorizations requirement:
The Authorizations team will request for a prior authorization, if required as per the payer specifics before the start of care. Authorizations are requested from the payer either through payer Utility Management intake lines, online requests, or through fax. The following medical documentations are submitted to obtain prior authorization from the payers:
· Referral document
· History & Physical notes
· Progress notes
· Surgical notes
· Plan of care (CMS 485
· Signed verbal orders
· Physician orders
· Evaluation notes for Physical/occupational/speech therapies & MSW
QA verifications:
Quality Assurance and Performance Improvement (QAPI) is a data driven and proactive approach to quality improvement. Gaps in systems are addressed through planned interventions with a goal of improving the overall quality of life and quality of care and services delivered to nursing home residents. The QA verification team will review the orders for skilled nursing (SN) and therapy disciplines. The clinicians will be notified for any changes or corrections on the orders.
OASIS review:
OASIS stands for “Outcome and Assessment Information Set.” It is a patient-specific standardized assessment tool used in the home health setting for patients insured through Medicare. It's used to provide quality metrics, determine reimbursement, and must be completed by providers as a part of the patient plan of care. An OASIS reviewer is typically a nurse- but could be another clinical specialty such as physical therapist. The main responsibility is to ensure accuracy on OASIS and remain compliant. OASIS assessment is used to monitor the quality of home health care to ensure that the needs of patients are properly met. It measures patient outcomes by tracking the health status of home health care patients over time. It is also useful in analysing health care processes and methods in the home health care field. There are six different types of OASIS:
• Start of care
• Resumption of care following inpatient facility stay
• Recertification within the last five days of each 60-day recertification period & Other follow-up during the home health episode of care
• Transfer to an inpatient facility
• Death at home
• Discharge from agency
Coding:
Coding team is responsible for uploading the primary and secondary diagnoses on the patient’s OASIS based on the diagnosis mentioned on the referral or signed MD documents and the reason for home bound care. Each diagnosis will be marked with onset/exacerbation date and the severity is marked based on the agency specifics.
Orders Management:
Orders Management is the process of collecting the home care orders from the physicians which is required before billing a home health claim to the payers. The following home care orders are sent to the physician’s office for signature through fax/mail/courier. The physicians will manually sign each of the order and will return it back to the Agency. These orders are collected and will be required when there is a recovery audit performed by the payers. There are few electronic applications like Suture Sign for sending/receiving the signed orders. The following orders require a physician signature and date:
Physician orders
CMS 485’s
Face-to-face encounters
Post hospital orders
SN visits
SN discharge summaries
Therapy evaluation notes/visits
MSW evaluation
Charges and Billing:
A home health care biller must be able to understand medical terminology and billing codes and use them correctly on claim forms. The roles of a home health biller are as follows:
• Transmits RAPs
• Transmits Finals
• Transmits/Processes Claims
• Pre-billing Audits
• Copies Notes, etc.
• Medical Records
• Giving them input and collecting any new files and information for billing
• Filling out insurance forms & ensuring they are properly coded before claims submission
• Processing files
Request for Anticipated Payments (RAP) general information:
• RAP may be submitted based on a verbal order
• RAP may NOT be submitted until the agency has completed the first billable visit within each episode/period; exception
• Rap not subject to payment floor
• RAP subject to MSP – takes longer to process Z=$0
• RAP can auto cancel:
If the final claim is not received within 90 days of the statement FROM date of the RAP, or 60 days from the paid date of the RAP, the RAP payment will be cancelled automatically by Medicare claims processing systems.
Billers are responsible to make sure the following data filled on an UB04 claim form are correct and valid:
Type of bill (field 4)
Priority of admission or visit codes (field 14)
Point of origin (field 15)
Patient status codes (field 17)
Condition codes (field 18-28)
Value codes (field 39-41)
Revenue codes (field 42)
HCPCS/Rates/HIPPS rate codes (field 44)
Occurrence codes (field 31-34)
Payments:
MACs send remittance advice in either an:
· Electronic format (Electronic Remittance Advice [ERA]),
· Paper format (Standard Paper Remittance Advice [SPR]).
Medicare contractors can use one of two formats to transmit provider electronic claim payments to financial institutions:
• Automatic Clearinghouse (ACH) format, or
• Table 1 of the Accredited Standards Committee (ASC) X12 835 version 5010 implementation guide which was adopted as a national standard under HIPAA for electronic payment and remittance advice. Both of these formats are considered national standards.
Rejections and ADR’s:
Common Rejection Problems, issues, challenges
• Requirements of face to face not met
• Requested medical records not submitted in timely manner
• Information provided does not support medical necessity
• Appropriate OASIS not submitted
• POC/certification signed but not dated
Requested medical records not submitted in timely manner:
• Provider has 30 days from the time Additional Development Request was generated to respond:
• Clerical assignment to log in and track
• Set deadline 72 hours before true deadline and live by it!
• Establish a uniform process that ensures you have time to review the documents before sending them.
• Monitor your direct data entry (DDE)
• Always attach copy of ADR request to top of what is sent.
CMS ADR Edit Types
• Probe
· Service
· HIPPS
· Physician
· Diagnosis
· CBSA
• Provider
• Beneficiary
• Late OASIS submissions (RAC rationale handout)
Medicare DDE:
Medicare DDE will allow us to perform the following activities:
• Key and submit UB-04 claims
• Correct, adjust and cancel claims
• Access the Revenue Code, HCPCS code and ICD-10 code inquiry tables
• Access the reason code and adjustment reason code inquiry tables
• Inquire about the status of claims
• Inquire about the need to respond to an ADR
Providers send Medicare Part A claims to the Fiscal Intermediary Standard System (FISS) for processing. The Fiscal Intermediary Standard System (FISS) is the standard Medicare Part A claims processing system.
It allows you to perform the following functions:
• Enter, correct, adjust, or cancel your Medicare home health billing transactions
• Inquire about the status of claims
• Inquire about the need to respond to an additional development request (ADR)
• Access various inquiry screens (e.g., revenue codes, diagnosis codes, reason codes, etc.)
Suspended Claims:
When a claim is being worked by Medicare it is in "suspense", which means in most cases, the provider won’t need to take any action. However, if Medicare finds something wrong with a claim, it can return it to the provider (RTP), reject it, deny it, or request additional development.
Claims Correction (T-STATUS):
When a provider submits a claim that includes incorrect information, Medicare issues a RTP claim indicating the provider needs to make fixes. Oftentimes, there are errors in patient name, gender and date of birth the provider must correct for a successful claim.
Rejected Claim:
A rejected claim means that the claim is not payable in its current state and must be corrected and re-submitted. This generally happens when a provider tries to bill the wrong payer or other eligibility issues arise.
A/R follow-ups and Denials:
Denied claims are the worst-case scenario because Medicare won’t pay them and a rebill isn’t allowed.
In order for a Home Health Claim to be denied, it must have gone through a "medical review". The most common cause for denials occurs when Medicare asks for a Request for Additional Development (ADR) to help determine medical necessity, and the provider fails to respond. The only way to rectify a denied claim is to appeal.
Appeals and Grievances:
Five levels of appeals in Home Health are listed as follows:
• Level 1 is a Redetermination, which is conducted by the MAC. A Redetermination is a completely new, critical re-examination of a disputed claim or charge. MACs have 60 days to complete a redetermination. If additional documentation is required, the processing time is 74 days from the date of the initial receipt.
• Level 2 is a Reconsideration. This appeal is conducted by the Quality Independent Contractor (QIC). You may only file a Reconsideration after you have submitted a Redetermination and received a response. All Reconsideration requests must be submitted in writing to the QIC within 180 days of receiving the redetermination letter. The QIC has 60 days to render a reconsideration decision.
• Level 3 is filing an appeal with the Administrative Law Judge (ALJ). ALJs hold hearings and issue decisions related to Medicare coverage determination that reach Level 3 of the Medicare claims appeal process.
• Level 4 is the Department Appeals Board (DAB) Review. The DAB provides impartial, independent review of disputed decisions in a wide range of Department programs under more than 60 statutory provisions.
• Level 5 is the Federal Court (Judicial) Review.