LEARNING CENTER

Is Your Home Health Agency Giving You Its Best?

Home Health Agency Benchmarks

Below are national benchmarks of agency performance. If your agency is not meeting any of these benchmarks, there are ways to improve listed in the information below. LTCM can assist you in making the changes needed to have an efficient and profitable agency.

Item  Benchmark Statistic 
Profit Margin  13.5% 
Recertifications  50% 
Therapy Patients  37% 
Non-Medicare Patients  30% 
Reimbursement Each Certification Period  $2,965 
Cost Per Visit  $143 
Therapy Visits per Episode  12 
Skilled Nursing Visits per Episode  9.6 

Source: Medpac Report to Congress, Home Health Services, March 2017

Common Pitfalls

  • Low reimbursement
  • Billing problems
  • Census below expectations
  • Regulatory compliance issues
  • Inefficient therapy utilization

Reimbursement Problems

  • Underutilization or overutilization of therapy: an agency does not make any additional money for 6 or fewer therapy visits or for 21 or more therapy visits per episode.
  • Low therapy visit frequency: an agency needs to be at 9 to 20 therapy visits an episode to be profitable.
  • Low scoring of functional need
  • Not claiming all the clinical diagnoses
  • Improper scheduling: a point system is recommended to efficiently staff and schedule an agency. A typical nurse should have 30 points a week assigned to be considered efficient. Point assignments: 3 points for an admission, 2 points for recertification or resumption of care, and 1 point for a standard visit.

Reimbursement Solutions

  • Review OASIS for functional scoring of 1 or more on dressing, bathing, transferring, ambulation and refer to therapy
  • Review therapy planned frequencies and require strict approval process for less than 6 visits or more than 21 visits
  • Nurses must have the patient demonstrate how they dress, bathe, and transfer to ensure maximum functional coding
  • OASIS scrubber catches overlooked errors
  • Focus marketing effort on more clinically complex patients or patients with more rehabilitation needs.

Payment Problems

  • Not billing timely not only can slow your cash flow, but cause the RAP money to get pulled back and you have to start all over again.
  • Failure to obtain pre-authorization for private insurance.
  • Failure to file on a timely basis for various private insurance plans. The filing deadline varies: 60, 90, 180, 365 days. Filing too late means you don’t get paid.
  • Failure to transmit claim according to private insurance guidelines.
  • Failure to follow up on claims to ensure paid.

Payment Solutions

  • Review accounts receivable each month
  • Review insurance claims every two weeks
  • Track active episodes
  • Complete an admission checklist:
  • Verification of payer/insurance and patient information
    – Pre-authorizations received and recertification call scheduled
    – Completion of face to face, 485, OASIS and comparison for consistency
    – Visit schedule in software matches care plan
    – Referrals sent

Census Problems

  • Lack of practitioner or referral source understanding of what qualifies a patient for home health.
  • Not recertifying patients and having a process to ensure thorough review prior to the decision
  • Misunderstanding the definition of homebound status
  • Focus of therapy providers on outpatient therapy

Census Solutions

  • Marketing, marketing, marketing!
  • Provider, referral source, and agency staff education
  • Weekly case meetings with nursing and therapy staff prior to recertification or discharge
  • Partnership with assisted living facilities

Regulatory and Quality Issues

  • Staff not meeting frequencies in care plan or orders
  • Failure to obtain orders for services provided
  • OASIS and 485 and F2F do not match
  • Lack of justification for recertification
  • Failure to educate on items listed on care plan
  • Failure to perform supervisory visits for LVNs and nurse aides
  • Failure to provide ABNs within 5 days
  • High hospitalization or emergency service rates
  • Failure to improve patients’ condition or decrease in patients’ conditions
  • Incidents and infections for patients during home health services

Regulatory and Quality Solutions

  • Chart audits performed regularly (a minimum of 20% of census)
  • Review 485 care plan on each visit
  • Provide educational documents
  • Monitor scheduling and visits for completion
  • Increase communication with staff regarding issues
  • Monitor and address OBQI and OBQM data

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