Home Health RCM

Home Health Billing: OASIS, PDGM & Medicare Compliance

From OASIS accuracy to NOA timeliness and PDGM optimization, our home health billing team turns clinical documentation into maximum-allowed reimbursement, with audit-ready compliance.

98.5% NOA Timeliness Rate
18% Average Reimbursement Lift
17 Days Average Days in AR
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The Challenge

Why Home Health Billing Punishes Generic RCM

PDGM, OASIS, HIPPS codes, face-to-face rules, LUPA thresholds, and NOA timelines are unique to home health. Generic medical billing teams don't have the clinical and regulatory depth to protect agency revenue.

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PDGM Optimization

30-day periods are paid based on clinical grouping, functional impairment, comorbidity, admission source, and timing. Every OASIS field maps to reimbursement, we audit for correct group placement.

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OASIS Accuracy

M-item scoring drives HIPPS codes. Our COS-C reviewers catch under-coded functional status, missed comorbidities, and inconsistent clinical grouping before periods are locked.

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Face-to-Face Compliance

F2F documentation must support homebound status and skilled need. Missing F2Fs mean denied claims. We track every patient's F2F and chase documentation proactively.

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NOA 5-Day Deadline

Notice of Admission must reach Medicare within 5 calendar days of SOC. Late NOAs lose 1/30th of the period payment per day late. We submit NOAs day-of whenever possible.

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LUPA Management

When a 30-day period falls below the case-mix visit threshold, payment reverts to per-visit. We alert scheduling in real time to prevent accidental LUPAs.

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MA & Medicaid Waivers

Medicare Advantage, Medicaid waivers, and commercial plans each pay differently. We manage authorizations, visit limits, and concurrent reviews across every payer.

Our Approach

Home Health-Certified RCM From OASIS to Cash

Our home health billing team includes COS-C certified OASIS reviewers, HCS-D certified home health coders, and HH-compliance specialists who understand the PDGM-era regulatory landscape end-to-end.

  • OASIS pre-lock review with clinical grouping and M-item accuracy audits
  • Primary diagnosis optimization aligned to PDGM clinical groups
  • F2F tracking with 60-day advance alerts for every admission
  • NOA submission automation with day-of filing whenever possible
  • LUPA threshold monitoring and real-time scheduling alerts
  • Denial and ADR response with clinical narrative support
Home health nurse visiting patient at home
18% Average Reimbursement Lift
98.5% NOA Timeliness
94% First-Pass Resolution Rate
17 Days Average Days in AR
Compliance & Security

HIPAA-Compliant Home Health Billing Operations

Home health data includes OASIS clinical assessments, F2F documentation, and 485 plans of care. Our operations align with HIPAA, ISO 27001, and HITRUST CSF.

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HIPAA & CoP Awareness

All PHI lives inside encrypted, access-controlled systems with audit trails. Our team is trained on HHA Conditions of Participation and survey-readiness documentation standards.

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ISO 27001 & HITRUST

Information security management aligned with ISO/IEC 27001 and HITRUST CSF. Continuous monitoring, least-privilege access, and documented incident response protect agency data.

FAQ

Home Health Billing Questions Answered

Related Services

Billing & AR Medical Coding Denial Management Eligibility & VOB Prior Authorization
The Patient-Driven Groupings Model (PDGM) pays based on 30-day periods (not 60-day episodes), with case-mix weighting driven by clinical grouping, functional impairment level, comorbidity, admission source (community vs institutional), and timing (early vs late). Accurate OASIS and primary diagnosis coding directly determines reimbursement, we audit every 30-day period for optimal PDGM placement.
OASIS accuracy is the single largest driver of PDGM reimbursement. We review Start of Care, Recertification, Resumption of Care, and Discharge OASIS assessments for clinical group alignment, M-item consistency, and functional score integrity. Our OASIS reviewers are COS-C certified and identify both reimbursement-depressing under-coding and audit-risk over-coding.
Medicare requires a physician or allowed NPP to complete a face-to-face encounter within 90 days before or 30 days after SOC, with documentation supporting homebound status and skilled need. Missing or non-compliant F2F results in denied claims. We chase F2F documentation proactively, review for clinical support language, and store them in a centralized audit-ready repository.
HIPPS (Health Insurance Prospective Payment System) codes are five-character alphanumeric identifiers derived from OASIS data that drive PDGM reimbursement. The first position indicates clinical grouping, second indicates timing/source, third indicates functional level, fourth indicates comorbidity, and fifth is a payment indicator. We generate HIPPS from OASIS and verify claim placement before submission.
LUPA applies when the number of visits in a 30-day period falls below a case-mix-specific threshold, causing the period to be paid per visit instead of at the full case-mix rate. We track visit counts in real time, alert clinical teams when periods approach LUPA thresholds, and coordinate with scheduling to prevent unintended payment reductions.
Since 2022, home health agencies must submit a one-time Notice of Admission within 5 calendar days of SOC. Late NOA submissions result in payment reductions of 1/30th of the 30-day period rate per day of lateness. We submit NOAs on day 1 whenever possible and monitor submission status to ensure no agency loses revenue to NOA lateness.
Yes. We've supported agencies through the RAP elimination and NOA rollout, and we continue to clean up legacy RAP-related payment issues, auto-cancellation reversals, and Medicare systems errors. For new agencies, we establish NOA processes from day one.
Medicare Advantage plans increasingly authorize home health on visit-limits or per-diem terms rather than PDGM episodes. We manage per-plan authorization workflows, visit tracking, and concurrent reviews. We also bill Medicaid waiver programs and private insurance home health with state-specific rules.
We integrate with Homecare Homebase, Kinnser/WellSky, MatrixCare, Axxess, Alora, Devero, Forcura, and CareVoyant. Our team configures charge capture, OASIS review workflows, and NOA submission directly inside your existing EMR.
Related Specialties

Adjacent Post-Acute & Long-Term Care Specialties

Hospice ›

Per-diem billing, levels of care, and NOE/recertification management.

SNF ›

PDPM, MDS 3.0 accuracy, and Medicare Part A/B split billing.

DME ›

Durable medical equipment billing and WOPD compliance.

Physical Therapy ›

PT billing, 8-minute rule, and Medicare therapy threshold management.