This, the final article in a series of three, will focus on the all-important billing and collections aspect of your relationship with managed care payers. Proper credentialing and meticulous attention to detail regarding the authorization process, discussed in detail in the first and second installments of this article, will have been for nothing if this final piece of the puzzle is not figured out. This is how you get paid! It matters! Take the time to get it right! Consider the following points when billing:

Claim Format and Electronic Claim File Format

It is in this area that many agencies fail. Can you really expect to get paid if a claim that meets all the payer requirements is not presented? I will answer that, NO! Make sure the billing manager has access to and has fully read the contract and the payer specific billing manual before the first claim is filed. These resources together should lay out a clear path toward accurate claim presentation and billing success. Use the following tips to get the desired result:

  • Understand the timely filing requirements for each payer.
  • What is the mailing address for claims or the electronic payer identification specific to the clearinghouse?
  • Do the codes on the claim match the codes in the contract/fee schedule?
  • Are there specific condition or occurrence codes required on the claims?
  • What is required on the claim in the authorization field? Is it the OASIS matching key (treatment authorization code) or the payer provided case specific authorization code?

Get any of this wrong and the end result will be confusing denial messages on the explanation of benefits (EOBs) that are difficult to understand and even harder to correct.

Software Concerns and Payer Setup

Getting the payer set up correctly in your software is the first crucial step to successful billing, but it is not a guarantee. In some systems, the payer setup process is complex and time consuming. There are even some systems that require that once the paper claim format of the payer is set up correctly, the electronic claim components of the payer must also be customized and specifically defined. Verify each of the following:

  • Make sure the appropriate billing code is assigned to each and every visit type in the system. Pay close attention to code distinctions between Start of Care (SOC) visits and Evaluation (EVAL) visits. Make sure LPN vs. RN visits and PT vs. PTA visits are properly coded. Often the fee schedule includes a premium for SOC and EVAL visits. Code them wrong and this premium will not get paid.
  • Turn on the software switch that allows for the inclusion of the OASIS generated HIPPS code. Showing the HIPPS code on the claim, even if the contract reflects reimbursement per visit, has been a Medicare managed care requirement since 07/01/14.
  • Properly enter the claims mailing address at the payer setup level
  • If required, choose the correct electronic claims format and be sure, if required, to define the electronic payer ID specific to the clearinghouse.

Once all this is done, verify the results when creating your first claims. Look closely at the coding on the claim. If there is a visit line with a code that is not on the fee schedule, corrections will have to be to made if you want to get paid. Check box 63 on the UB-04. Did the OASIS matching key or if required by the payer, the case specific authorization number pull to the claim? Did the HIPPS code make it to claim? This review is the last chance to make sure the claim is transmitted as a “clean” claim.


Prompt claim follow up is critical with a newly contracted payer. The contract signed by the agency with this payer has a prompt payment clause or commitment in it somewhere. This is the phrase that tells how long the payer has to process claims presented without errors. Have the billing team monitor the processing of these claims to see if the payer is following these prompt payment guidelines.

Make sure there is a system in place within the billing department to review and respond to denial notifications or requests for additional information from the payer. This process is very important, particularly in the beginning of your relationship with the payer. If you are billing incorrectly, make the necessary corrections in your software and refile the claims. If you are getting authorization denials get with the administrator and make sure authorizations are being secured correctly and that only authorized visits are being provided.

When the claims pay, compare the payments by discipline and visit type to your fee schedule. Is the payer processing the claims correctly? File appeals or corrected claims as needed.

Final Thoughts

Managing Medicare Managed Care can be a complicated and costly endeavor for a home care agency. An agency can do everything right and still experience payment delays and claims processing errors with payers. HPS recommends that you proceed slowly with taking these new referrals and have systems in place to measure the profitability of this new payer relationship. Consider, not just the hard direct cost related to the visits, but all the administrative costs as well. You may be getting all these new patients because the competition will not take them due to not being able to get paid. So often at HPS we hear, “We have to take these referrals or we will not get traditional Medicare cases.” This may be true, but if the relationship with these payers simply erodes already rapidly diminishing Medicare margins, is it really worth it?