Biller’s Role and Required Skills

The financial health of an agency is dependent on the performance of the billing department. Billers must understand requirements for eligibility, the claims submission and payment process, and how to participate in the appeals process.

Many skills are needed to be a home health biller. Billers should know how to do the following: 

• Establish eligibility with the understanding of a variety of insurance rules 

• Verify patients’ insurance coverage 

• Reduce risk of late or nonpayment by following timely filing guidelines 

• Creating a clean claim (i.e., one that follows rules and is accurate) for submission 

• Develop procedures to reduce accounts receivable (AR) days as much as possible 

• Follow a claim from initial payment to zero balance 

• Identify any appeals/denials and unpaid claims on remittance advice

•Understand requirements for refunds/paybacks

 • Handle collections on unpaid accounts 

• Use data and reports as performance indicators for potential areas of improvement

 • Answer patients’ billing questions 

• Manage the agency’s accounts receivable reports

 Home Health Billing

 A certified home health agency is authorized by the Centers for Medicare & Medicaid Services to accept Medicare and Medicaid reimbursement. Certified home health agencies must follow the Conditions of Participation 42 CFR 484 requirements. 

Certified home health agencies provide skilled and intermittent services to individuals in their home environment. Home health allows people to stay in the comfort of their own home while receiving active treatment or routine care during the healing and recovery phase of their illness or injury. Certified home health agencies offer many services, including the following: 

• Skilled nursing 

• Physical therapy 

• Occupational therapy 

• Speech language pathology 

• Social worker services 

• Home health aide services 

Home health providers negotiate contracts with private health insurances. The contract will have a list of the reimbursement rates along with the specific billing codes required for the claims. The federal government determines the reimbursement rate for Medicare and Medicaid. Medicare releases the reimbursement rates each year. These rates are found in the annual Prospective Payment System (PPS) home health final rule. Medicaid lists the rates on the Medicaid website. Medicaid does not change the reimbursement rates every year. 

Understanding the federal regulations and billing requirements of each insurance plan is essential to home health agencies receiving accurate reimbursement for the services provided. As billing requirements change so often, it is challenging for agencies to remain financially stable. 

Home health agencies must continuously review billing best practices to be able to provide the best care to beneficiaries. Home health providers are assigned to Medicare Administrative Contractor (MAC) jurisdictions.

 Each MAC offers providers ways to stay informed regarding requirement updates, manuals, and provider support. MACs are sometimes referred to as Fiscal Intermediaries (FI). Each MAC will have a listserv registration on the home page of their provider site. On the registration page, select the type of updates you would like to receive. General electronic data interchange (EDI) and education updates offer important information to the biller. Once registered, updates will auto-populate and be sent to your email address as the information is posted to the MAC site. 

Each MAC also offers customer service. Billers should contact their fiscal intermediary (FI) customer service department for claim status issues or EDI department for electronic claims and report issues.