How Home Health Providers Can Avoid Payment Denials

Payment denials can be costly and time consuming for home health providers, and they’re often self-inflicted.

In order to avoid this all together, home health leaders should educate themselves on the common reasons behind denials, and also adopt documentation techniques that will help their organizations stay compliant with Medicare’s coverage criteria.

That was the main takeaway of a recent webinar hosted by WellSky, an Overland Park, Kansas-based company that utilizes software and analytics to help providers across the continuum achieve better outcomes at lower costs.


One of the most prevalent claims errors is not including the signature of a certifying physician. Documentation not meeting medical necessity is another top claims error that providers make.

Other common claims errors include encounter notes that don’t support all elements of eligibility, and missing or incomplete certifications or recertification documents.

“If you get a SMRC, or a supplemental Medical Review contractor, request for additional information, and you don’t comply … they will notify your Medicare Administrative Contractor. That can initiate claim adjustments and/or overpayment recoupment actions through their standard recovery process,” Beth Noyce, of Noyce Consulting, said during the webinar presentation.


Providers are able to appeal, but this can be a lengthy and cumbersome process.

Noyce noted that providers looking to find the home health coverage and documentation requirements, in order to stay on the right side of compliance rules, should be aware that all of the information is available to the public.

“All of the things are published, everything’s available to you without having to spend a dime of extra money, and it’s all in the public domain,” she said.

Source: WellSky

On CMS’ site, providers will find access to the Medicare benefit policy manual chapter seven, which includes all of the coverage requirements that home health agencies have to follow to be able to get paid. Noyce referred to chapter seven as the provider’s “bible.”

“Don’t confuse this with the conditions of participation that surveyors use,” Noyce said. “These are the things that the Medicare administrative contractors are told they have to follow to look at your claims, and see if [providers] followed the rules for coverage.”

During the presentation, Noyce also went over the top five denial reasons. Each Medicare administrative contractor publishes their own top five.

Source: WellSky

One of the denial reasons that overlapped across multiple Medicare administrative contractors was the medical necessity for skilled nursing services not being supported by documentation.

“I’ve seen a lot of patient records where I can tell that the nurse did what they should have done, but the way they documented it does not tell me that they needed a nurse’s skill,” Noyce said. “I highly recommend that you be very specific. Refer to the patient’s condition frequently and specifically, not just their diagnosis, but how what you’re doing impacts them individually. Show how what you’re doing is medically necessary.”

Ultimately, Noyce believes that clinical notes can save providers, though it often sinks them.

“I’ve seen so many inadequate notes when I know that the clinician is competent and doing great care, but they don’t give me a reason to show that they deserve payments,” she said. “They don’t show me that they follow the rules.”

It’s important for providers to write clinical notes that accurately describe the patient’s reaction to care, record a detailed picture of the treatment and explain next steps.

“Avoid vague or subjective descriptions of the patient’s care,” Noyce said. “Never write, ‘The patient tolerated treatment well, caregiver instructed in medication management, continue with plan of care’ — be specific please.”

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