Consider Our Home Health Eligibility & Prior Authorization Solution

Article Highlights

  • Home health agencies are dealing more and more with private insurance companies, not just Medicare.
  • Working with private insurance companies comes with a unique set of eligibility and prior authorization requirements.
  • Work with PMB to alleviate administrative burden managing the Medicare and private insurance payer mix.


Home health agencies are accustomed to working with Medicare to make arrangements for services provided to patients. But, there is a growing need to better understand how to work with insurance companies to support private-pay patients.

In our discussions with home health agencies, we have observed a growing trend of patients having private insurance — rather than traditional Medicare. While traditional Medicare is still a predominant source of reimbursement for home health services, the private insurance trend will only continue to grow over time, creating a broader payer mix that needs to be effectively managed.

This means that home health agencies need to better understand how to work with private insurance companies to make sure that you meet their requirements and ultimately receive payment for services provided. Specifically, your home health agency needs a prior authorization solution to ensure that you are set up for success.

Key Difference in Private Insurance vs. Medicare for Home Health

Private insurance companies have different requirements that are more rigid and strict than what Medicare allows. Home health agencies have to learn to work through these differences, as they must now reach out to private insurance companies for approval for some types of service.

For example, you must complete the eligibility and authorization process to provide certain services within their schedule limitations. Perhaps you are allowed to perform 2 home visits per week over a 6-week period. Or, you can perform 1 visit over a 5-week period. The insurance provider will tell you how often you can visit the patient and what services they will cover during this timeframe. It’s very restrictive.

Medicare is different because you can essentially perform as many visits as you deem medically necessary to provide care for the patient and meet their goals of helping the patient get mobile, get out of the house, and not be homebound anymore.

What was a simple process going through Medicare can be troublesome for many home health agencies in comparison with going through private insurance. Home health agencies can feel very limited in what they can get approved through private insurance carriers. This can affect the quality of care provided to the patient.

The Role of Payer Rules in Home Health Settings

Providing quality home health care services is a constant balancing act between providers, nurses, and insurance companies. The provider wants what is in the best interest of the patient, the nurse wants to provide hands-on care through patient interactions, and the insurance company wants to protect their financial position by restricting the type and frequency of services provided.

Each stakeholder has their own set of goals, and oftentimes these goals do not align. Such is the case in getting medical procedures, exams, and medications covered by private health insurance companies in a home health agency setting.

Overall, the payer rules govern what will be covered under the patient’s plan, so these guidelines must be followed as closely as possible, even if your agency does not agree with the restrictive nature of the insurance company’s requirements. This is why the best way to help smooth out some of these bumps in the road is to optimize the eligibility and pre-authorization process.

Challenges With the Prior Authorization Workflow

Oftentimes, health plans will require prior authorization for costly medical procedures or tests that may require a specific diagnosis for coverage. For years, home health agencies have dealt with a much more lax process through Medicare. But, private insurance companies take prior authorization approvals seriously, and this can mean the difference in your patient receiving essential care or not and also you receiving payment or not for services you have already provided.

Any time authorization is required for a procedure or test, home health agencies must fill out lengthy paperwork and go through an entire process just to receive prior authorization approval. Submission of this paperwork, tracking, calls with the insurance company, and corrections can cause administrative burdens. Over time, this can add up and detract from your agency’s ability to provide quality patient care.

The key to maintaining a high level of patient care is to proactively pursue the approval of certain services so that your team can minimize the amount of time spent on the lengthy prior authorization approval process. This helps to ease administrative burden and improve patient quality of care.

For example, if you know that your patient is going to require more than the one visit every five weeks that their insurance covers, reach out ahead of time to see how this can be resolved. Success with the pre-authorization process often consists of quick and thorough communication in a timely manner. Not only does this improve operational efficiency by streamlining the pre-authorization process, but it also enables your agency to provide quality patient care and get full payment.

Adapting to the Medicare and Non-Traditional Medicare Mix

The differences between working with traditional Medicare versus private insurance companies are immense. It can be difficult for home health agency staff to keep track of the approval and authorization process for each insurance company that you work with.

As you know, it’s different working with Blue Cross versus Aetna versus United Healthcare versus other private insurance companies. The more your staff gains experience in prior authorization solutions for each company, the more comfortable your staff will feel navigating each company’s unique requirements. However, it takes a lot of time to catch on to these very different processes for each payor source.

Fortunately, you do not have to go at this alone. Patient care shouldn’t be negatively impacted because of challenges dealing with the authorization of certain services. This is where we can help by alleviating the administrative burden while your team finds its groove handling the unique payer mix.

How Precision Medical Billing Can Help

Precision Medical Billing (PMB) can take over the eligibility and prior authorization process for your home health agency. We will support your staff as you transition to handling a larger mix of private-pay patients and their unique insurance requirements. By utilizing our services, we can help your agency maintain a high level of patient care while we deal with improving operational efficiency.

PMB can take over as much of the prior authorization responsibilities as you need us to while your agency catches up. We can discuss your current needs, the latest trends in payer mix affecting your agency, and how to optimize processes for eligibility and prior authorization to put your team in the best possible position to support patient care and revenue collections.

As a home health care agency, you should be able to focus on quality patient interactions and care while being able to maintain billing efficiency. We recognize that it’s difficult to achieve both goals when new requirements are thrown into the mix. But, we can help.

Schedule a consultation with our team so that we can work together to identify a solution that works for you. We are experts in home health billing, and we have built a dedicated team of professionals to support each insurance company that you deal with. We look forward to helping your agency.