Claims Denied: 3 Tips for Getting Reimbursement in Home Care

The OASIS (Outcome and Assessment Information Set) data collection tool provides The Centers for Medicare & Medicaid Services and commercial third-party payers’ evidence of the home care needed by your patients. Although the OASIS claim process can be cumbersome and time-consuming to complete, most clinical and operational health professionals can easily provide timely and accurate data. When administrative and procedural errors do occur, it can result in claim denials and an interruption to your cash flow. Regardless of size, your home care agency needs to ensure a high level of accuracy and consistency with OASIS documentation.

The following items can help you identify possible areas for improvement and enhancement of your overall revenue cycle management process.

1. Document Face-to-Face Encounters
The Centers for Medicare & Medicaid Services (CMS) requires that a face-to-face encounter must take place within 30 days after the start of home health care and no more than 90 days prior to the start of care.

Certification of patient eligibility needs to include, but is not limited to, verifying that the patient:

  • Be confined to the home
  • Needs skilled services
  • Be under the care of a physician
  • Receive services under a plan of care established and reviewed by a physician
  • Have had a face-to-face encounter with a physician or allowed non-physician practitioner (NPP)

2. Establish a Clear Plan of Care/Certification
The certifying physician needs to approve a patient care plan that is clear and accurate. The plan should contain all of the related diagnoses and reference the patient’s mental status in addition to the following:

  • Types of services, supplies and equipment
  • Frequency of visits
  • Prognosis
  • Rehabilitation potential
  • Functional challenges
  • Permitted activities
  • Medications and treatments
  • Nutritional requirements
  • Safety measures to protect against injury

The plan of care may also include any instructions for timely discharge, referrals and other items as specified by the certifying physician.

3. Review Your Home Care Quality Improvement Process
It is important to make sure you have a consistent and efficient process in place to ensure claims are approved in a timely manner. Below are some steps to consider:

  1. Develop parameters for collecting and transmitting OASIS data to avoid automatic claim denial
  2. Provide routine training for clinicians and staff focusing on OASIS guidelines, changes and updates
  3. Evaluate your software to ensure you are utilizing the best tool for your agency
  4. Implement a quality improvement process that includes data analysis of claim denials to determine better ways to process claims
  5. Appoint a claims manager that can quickly process denied claims should they occur

Your patients deserve to get the care they need. Your staff deserves the time to deliver that care. A streamlined reimbursement process is a step to providing the time needed for quality care.

Concordance Healthcare Solutions is proud to be able to support the medical equipment and supply needs of patients throughout the entire continuum of care with a specialized focus on home care. We understand the issues facing home care agencies and have particular Home Care Provider Solutions to help support your management objectives, along with the flexibility to meet your specific logistical requirements.

Contact us to schedule a time to discuss your particular needs.

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