by Lynn Labarta, SimiTree

Is your home health or hospice agency struggling with insurance claim denials? You’re in good company. As we move into 2025, claim denials remain the #1 challenge affecting revenue cycles across the industry. But there’s hope – we’ve compiled the latest strategies and insights to help you overcome this persistent challenge.

Let’s examine the primary causes of claim denials in our sector:

• Medicare homebound status verification issues
• Face-to-face documentation gaps
• PDGM period confusion
• Medicare Advantage plan authorization complexities

• Terminal illness certification problems
• Level of care documentation gaps
• Missing physician narratives
• Notice of Election timing issues

• Implement robust homebound status verification- Home health
• Establish face-to-face documentation protocols
• Create PDGM period tracking systems- Home health
• Develop payer-specific authorization workflows

• Use specialized home health & hospice billing software
• Implement automated eligibility verification systems
• Set up PDGM period alerts- Home health
• Utilize NOE and NOA tracking tools

• Create dedicated teams for Medicare vs. non-Medicare appeals
• Develop PDGM-specific denial protocols- Home Health
• Establish hospice-specific documentation review processes
• Implement specialty-focused staff training programs

1. Focus on specialty-specific staff training in home health and hospice billing requirements
2. Create separate workflows for different payer types (Medicare, Medicare Advantage (home health), private insurance)
3. Implement weekly PDGM period reviews- Home Health
4. Establish clear communication channels between clinical and billing staff

The home health and hospice landscape continues to evolve, but with proper strategies in place, your agency can thrive. Focus on building robust processes that address the unique challenges of our industry while maintaining compliance and optimization.

1. Evaluate your current denial rates by payer type
2. Assess your PDGM period management effectiveness- Home Health
3. Review your hospice documentation protocols
4. Implement targeted improvements based on your findings

Remember, reducing claim denials isn’t just about better processes – it’s about ensuring your agency’s financial health so you can continue providing essential care to your community.

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Lynn Labarta, VP of Post Acute RCM and the founder of Imark Billing (now SimiTree) has a wealth of experience in the healthcare industry. Lynn provides comprehensive billing services for home health and hospice agencies, streamlining their revenue cycle management process while supporting and managing billing challenges and compliance with evolving healthcare regulations and managing billing challenges; essentially acting as a key partner to ensure accurate and timely claim submissions and optimal revenue collection for agencies.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com