When we advise clients, we preach preach preach that the intake process is the foundation for successful home health billing. Why?
Intake gathers all the pertinent information for the patient which makes it possible to successfully bill the claim, so you can get paid.
Today, you will learn what the home health intake process includes as well as tips to reduce stress on your staff and increase revenue.
Intake (a person on your team or a partner that handles your home health billing) is responsible for gathering patient and insurance information. The intake person should be detail-oriented. Things like correct spelling, social security number, Medicare HIC number, and payer information are crucial. Something as simple as the transposition of a number can result in a denied claim.
The intake process will be different depending on a patient’s insurance, commonly referred to as the payer.
The common payer scenarios you will encounter in an intake process are:
Here’s the admission processes you need to be aware of for each of these payers.
Medicare-certified providers can accept patients that have traditional Medicare. To bill Medicare, a provider must have applied to be an approved provider and have obtained a National Provider Index (NPI) number. If you are in a state that has implemented the Review Choice Demonstration (RCD), Medicare requires that claims include a Unique Tracking Number (UTM)) to receive payment.
If a patient has insurance that an agency has a contract with, they are considered in-network. In-network patients should already be set up in the Electronic Health Record (EHR) system.
In the EHR, the payer should be set up based on what the contract states including how it’s billed, if they want one unit per visit or 15 minute increments per unit, and then the HCPC codes. All of this should be set up when the contract is put in place.
The charged amount can be adjusted based on an agency’s agreement with a payer. The charged amount is what you bill for a service. A contractual adjustment is the difference between what you bill and what you are paid based on the agreement terms.
If a patient’s insurance is not in-network, the agency must determine their out-of-network benefits for home health and confirm details regarding coverage. Keep in mind that some payers will not allow a patient to receive care from an out-of-network agency if there’s another agency in-network within a certain radius.
The payer may have a policy that the patient should use their benefits for an in-network provider within the range. If there isn’t an in-network provider within the range, it’s up to the agency if they want to accept the patient based on their out-of-network benefits.
In most cases, a patient will be responsible for the deductible, co-insurance, or co-pay. In a lot of cases, PPO plans are big payers in out-of-network services. However, you can’t always go by what the out-of-network benefits say. It is best practice to call the insurance company to gather additional information in regards to their out-of-network benefits.
Out-of-network benefits may cover a certain number of visits, may only cover skilled nursing services, may have a cap on benefits for therapies, or any of those in any combination.
Let’s say a patient has a maximum combined benefit of $3500 per year.
The patient may have used $2,000 of the outpatient therapy benefit, but an agency wouldn’t know that until they call to verify coverage. It’s up to an agency to accept the patient based on the out-of-network benefits and given information.
If an agency decides to accept the patient, it needs to obtain prior authorization for care. This can be accomplished using the payer’s online portal or by calling the payer directly. Make sure to confirm the number of visits your agency is able to provide. It is best practice to save a copy or document the authorization and attach it to the patient’s record (within the EHR) with the start and end dates approved in the authorization.
As far as out-of-network, authorization is payer specific. Speak with the authorization department to determine if they upcode or downcode and if you have to get authorizations for PT/PTA, SN/LPN, OT/OTA, psych visits, etc.. If you have psych visits, sometimes they have their own type of authorization. It just depends on each payer.
Consider other factors such as upcoding and downcoding. Asking questions is in the best interest of your agency. You need to know if you have to have authorization for the LPN and the RN specifically.
As an example, let’s say an agency is in a contract, and RNs are paid at $110 and LPNs at $90. Depending on the contract but in most cases, when you’re in-network, you don’t have to get separate auths because the payer will automatically know if you’re using an RN or LPN based on the HCPC code that you bill. The payer will upcode or downcode the claim based on the authorization.
Don’t forget to attach your visits. As part of the intake process, visits should be attached to the authorization so that claims can be generated.
Be sure that you don’t exceed that number of visits covered under the authorization. If you exceed the number of visits, you could face a denial and not be paid for the additional visits.
When a claim is ready to be billed, the biller reviews all information to ensure accuracy. They verify that the insurance ID, the number of visits, the units, and the patient’s demographic information are all correct. They also confirm that the diagnoses are added and there’s a doctor on the claim. Finally, they make sure they’re billing with the correct type of bill and that the claim is being sent to the correct payer. Those intake pieces are crucial to creating an accurate, clean claim.
There are many actions and pieces to appropriately complete the intake process and many agencies have a team of people who complete the different pieces. Intake builds the foundation for successful billing. When you see trends within your intake process that are contributing to inaccurate or unsuccessful billing, share with your team or staff so it doesn’t continue to happen.
