- Patient Eligibility Verification for Home Visits
- Obtaining Insurance Authorization: Varying Payer Policies for Home Health Services
- Specific Preauthorization Challenges for Home Health Services
- Tips for Streamlining Verifications and Authorizations for Home Visits
- Consider Outsourcing Verifications and Authorizations
Home health agencies deliver high-quality, personalized care to patients of all ages in the comfort of their own homes. Insurance preauthorization is typically necessary to provide those services at the patient’s residence. As a result, home health providers often collaborate with Medicare and private insurance providers to obtain preapproval before any home visits can be scheduled or conducted. While both Medicare and private insurance cover home visits, their eligibility criteria and prior authorization requirements differ significantly. Private insurers, in particular, tend to have more stringent requirements. Completing the patient eligibility verification and prior authorization process successfully is key for delivering quality care and for accurate home health medical billing.
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Patient Eligibility Verification for Home Visits
Correctly verifying patient eligibility for home health care services is a crucial step to ensure timely and accurate reimbursement. The process starts before the patient is admitted to skilled nursing or home health. During this time, it’s important to verify the following information:
- Demographic details: The patient’s name, date of birth and policy number.
- The payer: Medicare, Medicaid or commercial insurance (name)
- Insurance coverage: Verifying if the patient’s insurance plan covers home health services.
- Homebound status: Confirming that the patient meets the criteria for homebound status, which is often a requirement for Medicare coverage
- Benefit Limits: Determining the extent of coverage, policy type, coverage, effective dates, including co-payments, deductibles, and benefit limits specific to home-based care.
- Authorization requirements: Checking if insurance prior authorization is needed from the insurance provider for specific services or a certain duration of care.
Accurately verifying patient eligibility for home health services helps prevent unnecessary claim rejections due to eligibility issues and deliver quality care. After the insurance eligibility verification process is complete, the next step is obtaining preapproval for providing home health care.
Obtaining Insurance Authorization: Varying Payer Policies for Home Health Services
Obtaining timely prior approval from the insurance company for specific home health services is essential to ensure timely reimbursement. Insurance companies have varying authorization requirements: some may require one-time approval, some may need approval before each appointment, and others may not require any authorization at all. Let’s take a look at varying payer requirements for home health services.
- Medicare: People who are 65 or older or have certain disabilities may be eligible for Medicare health care services if they meet certain eligibility criteria, and the services are considered reasonable and medically necessary for the treatment of the illness or injury. The patient must be certified as “home-bound”. Medicare typically covers short-term skilled nursing facility stays and part-time home healthcare services provided by a Medicare-certified agency. However, it does not cover long-term care services.
- Medicaid: Medicaid may cover long-term care services for low-income individuals, but coverage and eligibility varies from state to state.
- Commercial insurance: Private health insurance policies often cover some home healthcare services, though coverage for long-term care varies. Managed care organizations may provide long-term care, home health, and hospice care services, but coverage and eligibility can vary.
Specific Preauthorization Challenges for Home Health Services
Home health agencies face increasing challenges in navigating the complexities of private insurance reimbursement.
- Strict insurance rules: Unlike Medicare, private insurance often places rigid limits on the frequency and duration of home health visits. This can hinder timely care and recovery.
- Complex authorization process: Many insurance plans require prior authorization for costly procedures or tests, involving lengthy paperwork and administrative hurdles. Submitting the paperwork, tracking the request, and calling the insurance company can cause administrative burdens.
- Limited authorization periods: Insurance companies may authorize services for a specific period, requiring repeated authorization requests as patient needs evolve. For example, the agency may have requested four weeks of physical therapy with 2 sessions per week, but if the patient has only regained half of the range of motion that is expected, they would need two additional weeks. This typically requires another prior authorization. This can lead to delays in care and potential payment issues, in addition to additional paperwork.
- Multiple prior authorization requests: Some payers will only authorize one appointment or one specified period of time at once, meaning that the agency must submit prior authorizations multiple times based on the patient’s needs and the payer’s requirements. Missing authorization deadlines can lead to loss of payment if services are provided.
Tips for Streamlining Verifications and Authorizations for Home Visits
- Eligibility verification: Check the patient’s insurance eligibility before scheduling a home visit. Verify policy coverage, effective dates, and benefit limitations specific to home-based care.
- Prior authorization: Along with the prior auth request, submit necessary clinical documentation outlining the medical necessity for home visits.
- Service verification: Confirm that the services requested fall within the patient’s covered benefits. Report the correct billing codes (CPT codes 99341-99350) and appropriate modifiers.
- Documentation: Maintain detailed records, including physician orders, progress notes, and care plans. Ensure timely submission of supporting documents to the payer for review.
- Payer-specific rules: Stay updated on changing guidelines from payers regarding home visit authorizations. Follow Medicare, Medicaid, and commercial insurance policies closely to ensure compliance.
- Approval confirmation: Obtain written or electronic confirmation of approval before providing services. Document authorization reference numbers and approval dates for future claims processing.
- Automated reminders: Using electronic health records (EHR): with automated reminders can help track authorization deadlines and avoid disruptions in care.
- Database: Maintain a database listing which insurance providers require authorization for common home health services. This reference tool can expedite the authorization process, especially for repeat clients, saving time and effort.
Consider Outsourcing Verifications and Authorizations
Partnering with an insurance verification company is an ideal way for home health agencies to confirm patient coverage and benefits. Such companies have multiple teams to manage each stage of the process. They will ensure that all the necessary information is collected during the pre-admission process, preventing delays in authorization or admission—or to services rendered without payment. Expert support can:
- Minimize the risk of denied claims due to incomplete or missing approvals.
- Help secure accurate and timely payments
- Improves patient care by eliminating administrative delays and ensuring uninterrupted services.
- Maintains compliance by handling the unique payer mix and keeping healthcare providers compliant with payer policies and regulations.
Insurance authorization and verification services can help home health agencies streamline their operations, allowing them to focus on patient care while ensuring timely reimbursement. By efficiently communicating with payers and securing necessary approvals, agencies can deliver care with confidence.
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