Home health billing & credentialing

How to get a home health agency Medicare certified

Start with the state license: federal rules require one wherever state or local law licenses HHAs. Certification then runs in a fixed order:

• CMS-855A enrollment with your Medicare Administrative Contractor (MAC), which must recommend approval before any survey takes place.
• Reserve funds. Under 42 CFR 489.28, you need enough funds to run for three months after billing begins, not counting Medicare receivables, held from the day you apply. At least half must be your own money, not borrowed.
• A survey by the state or by an accrediting organization (ACHC, CHAP or The Joint Commission). The State Operations Manual says state surveys of new applicants are typically a lower priority.
• Skilled care for at least 10 patients before the survey, not necessarily Medicare patients, with 7 under care on survey day, and proof you can transmit OASIS data.

The MAC then rechecks your enrollment and reserves, and CMS sets your effective date. Medicare pays nothing for care before that date, and notice of it can come many weeks after the survey.

Medicare home health billing, kept short

Since January 1, 2020, Medicare has paid in 30-day periods under the Patient-Driven Groupings Model (PDGM), grouped by diagnoses, OASIS function score, admission source and timing. Certification runs in 60-day periods. The rules that catch new agencies:

• OASIS timing: the initial assessment within 48 hours of referral or on the ordered start date, the comprehensive assessment within 5 days of the start of care, and submission within 30 days.
• The Notice of Admission, due within 5 calendar days of the start of care. If it is late, the payment loses 1/30th for every day from the start of care until filing, at the agency’s cost.
• The Review Choice Demonstration in Illinois, Ohio, Texas, North Carolina, Florida and Oklahoma, extended in 2024 for five years: you choose pre-claim or postpayment review, and postpayment is the default.

Who pays a non-medical home care agency

Four kinds of payer, each with its own rules:

• Private pay: families pay under your service agreement, with no enrollment.
• Medicaid waiver and personal care programs, paid by the state or through managed care plans. Enrollment varies by state. In Virginia’s CCC Plus waiver, for example, a personal care agency must be licensed or accredited and enroll with the state first (one agreement per service), join each plan’s network and have an RN supervise its aides.
• Long-term care insurance: policies set their own terms, so confirm the claim steps with the insurer.
• VA: aides in its homemaker and home health aide program work for an organization with a VA contract. Agencies are not enrolled automatically: you join the Community Care Network through Optum (Regions 1 to 3) or TriWest (Regions 4 and 5) and file claims within 180 days.

Electronic visit verification (EVV)

The 21st Century Cures Act requires EVV for Medicaid personal care services (from January 1, 2020) and home health care services (from January 1, 2023), under waivers and state plans, in fee-for-service and managed care. According to CMS’s FAQ on the law, it verifies the service, the client, the date, the location, the caregiver, and the start and end times.

Each state chooses its system. Have it running before the first Medicaid visit, and learn your state’s rule for missed clock-ins.

What new agencies get wrong in the first six months

The costly mistakes, all avoidable:

• Serving Medicaid, VA or insured clients before that payer has enrolled you.
• Treating the license as Medicaid enrollment; each managed care plan is another step.
• Letting HHA reserve funds dip before three months of billing.
• Expecting Medicare to pay for the 10 survey patients.
• Late Notices of Admission.
• Starting Medicaid visits before EVV is ready.
• A legal name, EIN, NPI or address that doesn’t match everywhere.

How Reliable Care helps a new agency

One team for enrollment, claims and your online presence:

• Credentialing and payer enrollment: the CMS-855A, Medicaid and each plan, VA, Medicare Advantage and commercial payers, with weekly follow-up and effective dates in writing.
• Full-service billing at 3% to 6% of collections, no setup or onboarding fees, monthly-minimum plans for new and smaller agencies: eligibility checks, authorizations, Notices of Admission, 30-day and authorized-hour claims, posting, denials, reports.
• A website and social media package for new agencies, quoted after a free review.

Your billing rate is set by your volume and confirmed in writing before we start.