Technology now helps home health care providers catch errors before they reach the payer — but issues such as incomplete documentation or missing clinician signatures can still cause delays.

The process begins with intake and eligibility, then continues through clinical documentation, assessments, coding and claim submissions, experts told Home Health Care News.

“Billing starts the moment a referral comes in, and it doesn’t wrap up until the payment actually lands,” Dan Borraga, senior vice president of operations at Interim HealthCare, told Home Health Care News. “I like to think of it less as a finish line and more as a relay race.”

Interim HealthCare, based in Sunrise, Florida, provides home health, personal care and hospice services across more than 300 locations in 44 states.

Billing starts with intake and eligibility, where Interim confirms the payer, plan type and whether the patient qualifies for the home health benefit, he said. Then, Interim collects information necessary for the billing claim, which includes a qualifying face-to-face encounter, physician or allowed-practitioner orders, the start of care visit.

Additionally, Borraga said providers must include a physician-certified care plan and the Outcome and Assessment Information Set (OASIS), which assesses the skilled home care a patient receives.

“Clinical documentation and the OASIS scoring are quietly doing the heavy lifting, as they drive the coding and case-mix grouping that set the claim’s value,” Borraga said. “Once the period closes and every order is signed and in hand, there is a pre-bill workflow review and then the claim goes out. Anything short-paid or denied heads into follow-up and appeals, and every dollar gets reconciled and posted where it belongs.”

However, Borraga added that billing rules vary by state. For instance, some states require physicians to sign orders within 30 days, while others mandate pre-claim review by a Medicare Administrative Contractor before a provider can submit claims.

Beyond state-by-state variation, different payers may have different requirements for billing, said Kevin Rogers, chief operating officer and chief financial officer of VNA Health Group.

“For commercial payers, they may require a particular note or a particular code be put in that you might miss, and it gets denied,” Rogers told HHCN. “You put it in, and then you refill it and gets paid. That happens every day. But as far as billing to Medicare incorrectly, that’s fairly rare.”

Neptune, New Jersey-based VNA Health Group provides home health, hospice, pediatrics and family health services across numerous locations in New Jersey.

The Centers for Medicare & Medicaid Services (CMS) have reported that insufficient documentation accounted for 51.4% of improper home health services payments, while medical necessity, incorrect coding, no documentation and other errors comprised the remaining reasons for denied payments in the 2024 reporting period.

While the rates of errors may shuffle around over time, the most common types of errors tend to stay the same, said Katie Wehri, vice president of regulatory affairs, quality and compliance at the National Alliance for Care at Home (the Alliance).

“That face-to-face encounter documentation is usually always one of the top three, and sometimes it’s just missing. It hasn’t been included in the response. That’s an easy error to fix,” Wehri told HHCN. “It’s the documentation within it that is sometimes a little more difficult.”

The Alliance is an advocacy organization composed of over 2 million healthcare professionals working in home health, hospice, home care, palliative services and Medicaid home- and community-based care.

Nailing documentation

Home health billing requires a signed, dated physician certification and plan of care, documentation of the face-to-face encounter necessitating the home health visit, clear documentation that the patient is homebound and needs skilled care, a completed and locked OASIS and signed visit notes matching what the provider is billing, Borraga explained.

“Every order has to be authenticated before that final claim goes out, and this is where a lot of otherwise-clean claims get stuck,” Borraga said. “Unsigned orders are one of the most common reasons a claim can’t drop on time, so agencies pour real energy and resources into what I’d call the gentle art of the cadenced follow-up — politely, persistently nudging physicians and allowed practitioners until those signatures come back inside the required timeframes.”

The reason for such thorough documentation is that the record must tell a complete, coherent story that the patient is qualified for home care and that a physician actually delivered medically necessary, skilled care, Borraga said.

“If the chart can’t tell the story, the claim can’t make the case,” Borraga said.

Since home health billing requires thorough documentation, problems often consist or timing or completion errors, such as late or unsigned orders and certifications.

“Documentation timing is by far the biggest cause of delay,” Borraga said.

Other issues could stem from the patient’s eligibility, such as a patient qualifying for Medicare Advantage instead of traditional Medicare, or they had a payer change not reflected in the referral information. Additional delays could stem from documentation not supporting the patient’s homebound status, or that the visits billed mismatching visit notes.

“Even when a claim is perfectly valid, additional documentation requests and audits can still hold up the process,” Borraga said. “Most denials aren’t mysteries; they’re the same handful of problems wearing different hats.”

Catching errors before billing helps reduce delays by implementing efficient intake workflows, quality assurance reviews of the OASIS orders and using automated claim scrubbing to flag issues before submission.

“What separates the mature operations is that they don’t just patch individual claims —they trend those denials back to a root cause and fix the process upstream,” Borraga noted.

Technological safeguards

Technology has largely streamlined how home health providers bill — including how they catch errors. Such tools include electronic medical records systems and third-party software with built-in OASIS logic, coding assist tools, automated eligibility checks and dashboards that illuminate denial patterns, Borraga said.

“At Interim, we’ve leaned into innovative AI-based tools that improve our speed, efficiency and accuracy on what is a very complicated algorithm,” Borraga added.

Technology is a big reason why VNA Health Group rarely sees billing errors, Rogers said.

“It’s kind of rare to have something go out that is quote-unquote wrong,” Rogers said. “That would be fairly rare without a lot of steps being missed.”

Rogers had been at VNA Health Group from 2005 to 2012 serving as the company’s vice president and CFO, before returning to the company in 2018. Over his tenure, he noticed the steep degree to which technological advancements augmented home health billing systems.

“Over the course of 15 years, the technology has improved so much and allowed us to do so much more. It’s mind-boggling,” Rogers said. “In the old days when it was paper, [errors] could happen. But nowadays, there’s so many triggers and stops that you just don’t get to that point.”

The technology stops incorrect billing claims from going through, Rogers added. This means that incorrect claims will not be submitted, and that workers must stop and rectify the errors before they can continue with the documentation process.

If necessary signatures are not included, this could mean traveling to a doctor’s office.

“You have to sometimes get in the car with a dozen orders that need to be signed by Doctor X, and you have to sit in his waiting room until he’s ready to sign him, and that happens a lot,” Rogers said. “Therefore, we’re delayed in giving service, and we certainly can’t bill.”

An error-free Medicare claim will typically be paid within 14 days, Rogers noted. However, payments could take 30 to 45 days if the company needs to track down signatures or other document needs.

While delays can keep agencies from submitting claims in a timely manner, Rogers added that technology helps prevent compliance errors that could cause even costlier setbacks.

“You couldn’t possibly do this with the regulations that they have added on over the years without the technology,” Rogers said. “It stops you from doing anything wrong, but you still have to do a lot of stuff right in order to get it billed.”

Even the best technology requires human oversight. While, operationally, it is nearly impossible for a human to review every single claim, Wehri said agencies should have a process that identifies what number of claims need to be reviewed, what documentation is needed and a thorough process for rooting out issues.

“Clean claims start at referral and then at the bedside, not the billing office,” Borraga said. “When the clinical documentation is accurate, complete and timely right at the point of care, the billing pretty much takes care of itself. When it isn’t, no amount of back-end processes fully make up the difference.”