Home health care is a trend that is continuously escalating every year. The growing number of patients who prefer to take medical help at home rather than in hospitals is the main reason behind this. 

In order to get home health billing services, however, billing and paperwork need to be done accurately. Just one missing step can lead to a delay in care, a stop in services, or a denial of the claim. One of the major issues in home health billing is when either eligibility or prior authorization is not checked in time.

In the blog, we will, first of all, dissect the specific reasons why home health billing eligibility checks and prior authorization are so crucial. We will introduce you to a fictitious patient whose services were delayed just to amplify our point. 

After that, we will explain how the early checking of eligibility can help prevent home health billing denials and also reduce the incidence of billing delays in home health care. In the end, we will enlighten the role of Dilijent Systems in supporting agencies by smoothly handling all home health eligibility and prior authorization steps, even before the billing starts.

Story: When One Missing Authorization Delayed Care

Let’s get introduced to Mrs. Allen. She is a delicate 72-year-old lady who, after her hospitalization, requires home health care. Her doctor has prescribed her nursing visits, medication support, and physiotherapy. The home health agency was, in fact, very much ready to greet her with care services right away.

However, there was a hiccup.

Prior to the visit of the nurse, the agency needed prior authorization from her insurance company. This is where prior authorization comes into play: giving permission before proceeding with the service. The agency thought that everything would be alright, as they had dealt with this insurance quite often. Hence, they did not check eligibility again as they presumed that she was already covered.

The nurse's arrival at her house signified the end of the visit. The authorization was not there. Her health insurance demanded approval for physical therapy, and so the agency could neither bill nor get paid. The nurse informed her that they would have to put the services on hold until the authorization was granted.

• The approval delay stressed out Mrs. Allen.
• It affected her family with the same stress.
• It also put a stress burden on the home health care agency.
• A trivial step, early overlooked, later on, became a huge problem.

This incident emphasizes the necessity of both eligibility checks and prior authorization as a must-do before the start of care.

What Are Home Health Billing Eligibility Checks

The home health care billing eligibility checks entail verifying whether the patient's insurance is in effect and what services are covered under the plan. It is like checking for a ticket before gaining entry to an event. If the ticket is not valid, you can’t enter. Insurances operate the same way.

Eligibility checks inform the answers to questions like:

• Is this patient currently eligible for the insurance?

• Is home health care included in the services of the plan?

• What category of visits are allowed?

• Are there caps, rules, or exceptional stipulations?

• Does the insurance company require prior authorization?

• What documents does the insurance company need?

If the home health care agency incorrectly checks the eligibility, they may offer services that cannot be charged. This results in a loss of money, a denial of claims, and dissatisfied patients.

Eligibility checks are the foremost and most crucial step in establishing a robust and impeccable billing system.

Why Eligibility Verification Matters in Home Health and Hospice

The home health and hospice agencies are obliged to carry out eligibility verification for both hospice services and home health services prior to the dispatch of any staff to a patient’s residence.

Here are the causes:

1. Denial of claims is prevented

Most denials occur because the agency did not check coverage properly. If the insurance is inactive or has expired, all claims get rejected.

2. Unpaid visits are avoided

If a nurse sees a patient without prior eligibility checking, the agency might lose the visit as payment.

3. Billing delays are decreased

In case the coverage is not clear, the agency will have to keep calling the insurance company, which will be a cause of the delay in billing.

4. It helps to match the services to the coverage

Services are not universally covered. The eligibility checks indicate the benefits the patient is entitled to.

5. Agency revenue is safeguarded

Agencies without eligibility checks face losing money and financial risk.

6. Compliance is supported

There are rigid rules by insurance companies. Eligibility checks aid the agency in following them correctly.

In other words, eligibility checks are a shield for both the patient and the agency.

What Is Prior Authorization in Home Health Care

Prior authorization in home health care translates to the insurance company consent being a prerequisite for certain services. It is similar to asking for permission before doing something that carries a lot of responsibility.

The following are some of the most common services that require prior authorization:

• Nurse visits with a skill

• Physical therapy

• Occupational therapy

• Speech therapy

• Medical supplies

• Wound care treatment

• Special tools

Insurance companies are concerned about the necessity of these services being medical ones. It implies that the patient actually is in need of the treatment or care.

The home health prior authorization procedure involves:

• Insurance coverage verification for the patient

• Medical document collection

• Insurance company query submission

• Approval waiting

• Patient record updating

• Care team notification

• Service commencement after consent has been given

Billing cannot start without consent.that is the reason why the home health prior authorizarion process has to be done in advance.

How Dilijent Systems Helps Home Health Agencies

Dilijent Systems is at the forefront of streamlining the billing process for home health and hospice agencies across the United States. The company’s team takes care of all eligibility and authorization procedures prior to the billing, thus making the workflow hassle-free and tranquil.

They render assistance in the following ways:

1. They Carry out Extensive Eligibility Verifications

Dilijent Systems takes proper care of each and every patient’s insurance:

• Active or inactive

• Health plan type

• Home care benefits

• Number of visits

• Co-payments

• Deductibles

• Authorized and unauthorized patient visits

• Supporting documents

They double-check things and make sure nothing gets overlooked.

2. They Manage the Entire Prior Authorization Process

Dilijent Systems’ team deals with the complete home health prior authorization process, which breaks down into:

• Taking physician orders

• Requesting medical records

• Filling insurance forms

• Following up for approval

• Keeping the agency’s file updated

This helps prevent agencies from granting delays and denials.

3. They Protect Claims from Getting Denied

Dilijent Systems makes it possible for agencies not to face claim denials in home health billing through:

• Early detection of problems

• Correcting incomplete data

• Discovering coverage doubts

• Ensuring the correctness of information

• Interacting with payers

The outcome of this is clean claims and speedy payments.

4. They Help Cut Billing Delays

Dilijent Systems helps agencies manage billing delays due to home health care by doing all checks first. Billing becomes possible right after the start of visits.

5. They Give Cash Flow a Boost

Claim approvals that happen sooner will mean payment to the. The agency that will come sooner. Thus, it will be easier for the agency to maintain its operations.

6. They Provide Hospice Eligibility Assistance

Several agencies, at the same time, provide hospice care. Dilijent Systems does hospice services’ eligibility verification by covering everything that is needed for the hospice patient’s comfort (comfort care), as well as family support.

Conclusion

One of the most critical steps in home health billing is the eligibility checks and prior authorization. A single missed step can result in delayed care, denied claims, and lower revenue. The early checking of eligibility enables the agencies to comprehend the coverage, while the authorization guarantees that the services are approved before they start.

Dilijent Systems helps agencies by meticulously and accurately performing all these steps. Their personnel confirm that each patient is validated, each authorization is cleared, and each claim is set for clean billing. This leads to fewer delays, rejection of claims being averted, revenue being safeguarded, and patients being able to receive the necessary care without being interrupted.

What is the purpose of a prior authorization?

Prior authorization in home health care translates to the insurance company's consent being a prerequisite for certain services. It is similar to asking for permission before doing something that carries a lot of responsibility.

What is the important role of eligibility verification?

The home health care billing eligibility checks entail verifying whether the patient's insurance is in effect and what services are covered under the plan. It is like checking for a ticket before gaining entry to an event. If the ticket is not valid, you can’t enter. Insurances operate the same way.

Why is authorization important in medical billing?

Prior authorization in home health care translates to the insurance company's consent being a prerequisite for certain services. It is similar to asking for permission before doing something that carries a lot of responsibility.