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Medicare Home Health Billing Requirements

Nov 28

It is one of the most critical aspects of the health care system but has become more complex. This change is because Medicare now requires home healthcare services to be physician-managed and physician-recommended. This means that you need an expert in Credentialing Services who can ensure that your home health provider meets these requirements. 

This means that you need an expert medical credentialing service who can ensure that your home health provider meets these requirements.

This article will review some of the fundamentals of various Medicare standards for home care billing. Then, we'll look at a few covering limitations and explain why it's crucial to keep them in mind. Furthermore, we'll examine why you might require outside assistance from a team.


What specifications must home health billing meet for Medicare?

Ages 65 and older can enroll in Medicare health insurance programs. It covers hospital care, nursing home care, and hospice services through its Medical Assistance (MA) program.

Home health care is an in-home service provided by aides or other caregivers to assist when performing regular tasks, including bathing, dressing, and feeding. Home health can be delivered through various methods, including direct care workers who perform physical therapy tasks in patients' homes. Moreover, indirect care is provided by workers who visit patients regularly. Additionally, nurses are hired by hospitals to work within their facilities so they can provide whatever level of treatment necessary for their patient's recovery from illness. 


Medicare requirements

Specific requirements must be completed concerning the patient's need for Medicare to pay for home health services. So put, only some qualify for this kind of in-home medical treatment.

It is because when a doctor or licensed nurse practitioner treats a patient at their home or another similar place, Medicare has particular policies on what it will cover and what it will not. These rules are typically employed to ensure that only people with a specific medical need receive additional and pricey home health care.


Below are the other requirements that must be taken: 


  • Physician Involvement

Physicians must see the patient at least once every 60 days. The physician must be involved in the care plan, including discharge planning. They should work with other medical specialists, including physical therapists and social workers, to ensure that patients receive appropriate services following their hospital stay.

Since they must report any suspected abuse or neglect by family members responsible for caring for a patient on home health services, any suspicious circumstances surrounding an incident could put someone else's safety at risk (e.g., if there were signs of physical abuse).


  • Need for Skilled Services

Skilled services require a therapist who is licensed or certified by the state. Therapists must have at least two years of education and experience. It must include training in the clinical skills required to provide skilled nursing care and the administrative tasks associated with running a business.

The Medicare regulations provide that there must be a documented need for either a particular service, such as a physical therapist, occupational therapist, speech therapist, or other comparable specialists, or intermittent skilled nursing care for fewer than eight hours per day. Additionally, the requested services must be reasonable and adhere to fundamental standards for the required visits to meet the patient's demands.


  • Required Documentation

In order for a claim to be funded, there must be sufficient documentation supporting the patient's homebound status in their medical file, as well as details on the rationale behind the doctor's request for services.

The key to demonstrating medical necessity in this instance has thorough chart notes with the justification for the request and any extra information that may support the requirement for home health care. Documenting the patient's medical condition in radiology medical billing, for instance, and using comparable comments on the recertification should help demonstrate that they meet the three objectives of the above list.


  • Home Confinement

Medicare home health care must be administered by a doctor and be medically required Medicare-certified agency. The patient must also be confined to their home or private residence where they receive the services.

The most critical aspect of home health qualification is that the patient is confined to their home. This means they cannot leave without significant assistance from someone else, such as a close relative or caregiver who stays with them 24/7 and ensures that all needs are met, including medication administration and nutrition intake (if needed). 


The recommendation and management of home health care must come from doctors:

It is essential to understand that Medicare home health care billing requirements are not complicated. The physician must be involved in the care and treatment of your patient. Moreover, it must help in making decisions about their treatment and care.

Additionally, the patient and the recommending physician must meet in person sometime between sixty days before and thirty days after the start of home health care for this to occur. Additionally, there must be any financial ties between the treating home health doctor and the doctor who makes the recommendation. Regarding home medical billing services, this is a very crucial piece of information that must always be acted upon.


Who is eligible?

All individuals who satisfy all of these requirements and have Part A or Part B are covered:

  • You must receive services according to a plan of care that a doctor has established and is routinely reviewing. You must also be receiving care from a doctor.
  • You must require one or more, and a doctor must vouch for your need.
  • Competent nursing care on demand (other than drawing blood).
  • Physical therapy treatments and speech-language pathology are only covered if they are a precise, safe, and successful treatment for your illness. Only trained therapists can perform the benefits safely and successfully. They must be complex and reasonable in terms of quantity, frequency, and period. 


How many hours does Medicare cover for home health care?

Medicare will cover home health care if the patient meets eligibility requirements. The length of time a patient is eligible for Medicare depends on their medical condition. Still, most patients can expect to be covered for at least 60 days after meeting specific criteria.

These visits can happen seven days per week, with the only guideline being that the maximum number of hours cannot be exceeded (with exceptions).


What does Medicare not cover? 

  • 24-hour care at your residence
  • Delivered meals to your home
  • Homemaker services that are not part of your care plans, such as buying groceries, housekeeping, and laundry
  • When this is the only form of care you require, custodial or personal care that assists you with everyday routines (such as showering, dressing, or using the restroom)


Why Working with a Medical Billing Expert is Important?

Understanding the requirements for Medicare billing is essential because it can be confusing. You'll need to know how to handle the paperwork and insurance companies and how Medicare handles its billing process. Additionally, you'll want to keep track of Medicaid requirements so that your client isn't receiving incorrect bills from them after they've been referred by you or other providers in your clinic's network.

Suppose you need to figure out where all these pieces fit together. In that case, investing in a medical billing expert is vital—someone who understands what must be done for your office's practice of medicine (and thus its billings) to remain compliant with federal regulations on medicare claims processing standards."


In short, the Medicare home health billing requirements for providers are complex and can be confusing for many. We hope this article has shed some light on the topic of credentialing services and provided a few practical tips on navigating these requirements. Remember that medical billing is an integral part of your business. So it's essential to find out what Medicare will cover and what it won't before you start accepting payments from patients or clients.