As we come out of a challenging year for home health agencies—with some of the biggest regulation changes in decades, as well as a pandemic—the financial consequences of these changes are proving to be significant. From the patient-driven groupings model to increased LUPA rates to No-pay RAP, industry changes are affecting the way care is delivered as well as every agency’s bottom line.
This is precisely why the workflow, from intake to back office, must be effectively structured. The following are four workflow steps that drive claims accuracy and achieve effective revenue cycle management.
A critical first step in the workflow, your intake process should be calculated and planned with procedures in place to capture accurate information and to set the standard of care from the beginning. This includes:
Insurance verification and eligibility checks
Critical to intake function, these checks identify the primary payor and Medicare secondary payors. Getting this wrong at intake will cause denials and billing delays downstream.
Completion of face-to-face encounters
Completion of the face-to-face encounter should be confirmed up front, in addition to the certifying physician responsible to oversee the plan of care. The intake function should ensure there is an order for the initial assessment visit—a prerequisite for the RAP submission.
Confirming admissions source and timing
There must be a gap of at least 60 days between the end of one 30-day period and the start of a new one for the submission to be classified as early. This is why it’s important to validate the dates of previous periods from other home health agencies (or the same agency) at intake.
Supporting clinical documentation requested and received
Ensuring completion of this intake function will support accurate assessments by admitting clinicians and identifying valid PDGM primary diagnoses, as required for the RAP.
2. Comprehensive assessment
The initial billable visit, meaning that skilled care was provided, is necessary to establish the start of care. During this part of the workflow, most agencies also complete the comprehensive
assessment with OASIS items.
As part of the comprehensive assessment, the admitting clinician identifies and validates the primary diagnosis, comorbidities, and all other pertinent data to be included on the plan of care.
3. Plan of care development
The plan of care is developed based on the comprehensive assessment, which identifies the patient’s specific needs, interventions, and goals for care. This must be completed, reviewed by the physician, and signed and dated prior to submitting the final claim.
4. Changes in the patient’s condition
Any changes to the patient’s condition that occurred mid-episode and prior to the start of the second payment period are important to capture—as these status changes may impact case-mix and payment for the subsequent period of care.
It’s important for home health agencies to have a structured process to identify when there are significant changes to functional status, diagnoses, or transfers to inpatient facilities that occur between initial and subsequent periods. Agencies should also develop a closed-loop communications process with their quality review and coding system and back-office billing functions to ensure claims are updated when mid-episode status changes occur.
By ensuring these workflow steps are in place, your agency can capture more accurate documentation, prevent revenue loss, and most importantly, provide patients with better care.
For more expert tips on maximizing cash flow and revenue management best practices, download our eBook, Revenue round-up: Eliminate revenue loss from No-pay RAP and beyond.