Home Health Billing Services
End-to-end billing for home health agencies (HHAs), skilled nursing at home, and home infusion episode-complete compliance, faster payments, fewer surprises
You send caregivers into homes; we handle the paperwork that follows. Home health billing isn’t just “medical billing at the bedside.” It is episode-based, documentation-heavy, and audit-prone. Sirius Solutions Global provides clinical-first coders, HIPPS/HIPPS+ accurate mappings, and AI-powered workflows that catch missing physician certifications, face-to-face attestations, and OASIS-to-claim gaps before claims are submitted.
Full-cycle home health revenue cycle management
We don’t just submit claims we manage the episode from referral to final appeal.
1) Front-end intake & eligibility
-
Verify Medicare/Medicaid and supplemental benefits at referral.
-
Flag potential coverage issues (e.g., concurrent hospice, SNF crossover) and identify payers requiring special documentation.
2) Certification & face-to-face workflow automation
-
Track physician certification/recertification due dates, integrate e-signature and telehealth face-to-face attestations, and prevent claims for uncertified episodes. (This prevents the top reason for HH denials.)
3) OASIS / clinical documentation mapping
-
Validate required OASIS fields, map to HIPPS codes, and verify that clinical notes support the chosen HIPPS level preventing undercoding or audit exposure.
4) Coding, charge capture & HIPPS accuracy
-
Clinical coders with home-health experience review each episode’s documentation to ensure the right HIPPS code and correct revenue lines for skilled nursing, PT/OT/ST, infusion, wound care, and supplies.
5) AI-augmented claim-scrub & submission
-
Before claims go out we run an AI + rules-based scrub that checks for: missing certification, missing face-to-face, OASIS-claim mismatches, revenue & modifier logic, and payer-specific edits. High-risk claims are queued for clinical review. (Automation reduces rework and raises first-pass acceptance.)
6) Denial prevention, appeals & medical review defense
-
Root-cause analytics identify repeat deniers and defect patterns. We prepare clinician-backed appeals and compile audit-ready documentation packets to respond to medical reviews.
7) A/R follow-up & prioritized collections
-
Prioritize follow-up by estimated recoverable value (AI scores denials), escalate high-value items, and provide patient-friendly statements for non-covered charges.
8) Reporting & continuous improvement
-
Weekly dashboards: certification compliance %, first-pass acceptance, denial rate by payer/issue, A/R 30/60/90, and net collection rate. Monthly actionable playbooks to reduce the top 3 denial drivers.
Outcomes you can expect
-
Reduced certification/face-to-face denials by a significant margin (depends on baseline many clients see rapid improvement once workflows are enforced).
-
Higher first-pass acceptance through AI + scrub rules.
-
Shorter days-in-A/R via prioritized follow-up and high-value denial resolution.
-
Improved audit readiness with pre-assembled documentation bundles for medical review.
Why home health billing is different
Home health uses episode-based payments, requires timely physician certifications/recertifications, and depends heavily on OASIS/SOAP documentation to justify medical necessity and episode intensity. Key pain points:
-
Physician certification/recertification is critical. Medicare denies episodes when certifications are missing or incomplete that’s one of the most frequent denial causes for HHAs. We lock this down.
-
Face-to-face encounter verification. For Medicare-covered home health, a qualifying physician face-to-face encounter (or acceptable exceptions) must be documented and linked to the certification; missing or late face-to-face attestation causes denials and recoupments.
-
OASIS-to-claim mapping & HIPPS accuracy. OASIS items drive HIPPS/HHRG groupings and impact payment. Incorrect mapping leads to underpayment or trigger audits.
-
Episode timing, partial episode payments & transfers. Home health episodes have specific discharge/readmit and PEP rules misreporting discharge or transfer codes causes billing errors. CMS updates to HH PPS affect how episodes are priced and should be monitored.
Common home health billing problems we fix
-
Missing or late certification → episode denied. We track cert dates, auto-notify physicians, and prevent submission until valid certification is attached.
-
Face-to-face not documented / linked → claim recoupment. Our bundle builder attaches the attestations and cross-links to the claim.
-
Wrong HIPPS due to OASIS error → underpayment or audit. We validate OASIS entries and run a reconciliation step to avoid mis-grouping.
-
Partial episode payment (PEP) misreporting on discharge/transfer → incorrect payments. We detect PEP scenarios and apply the right occurrence codes and transfer logic.
Quick market snapshot what matters right now
-
Medicare’s Home Health Prospective Payment System (HH PPS) updates are active and can affect episode payments and rate-setting; for example, CMS finalized CY-2025 HH PPS updates that modestly changed payment levels and policy details.
-
Home health denials and medical reviews commonly focus on physician certification/recertification, face-to-face documentation, and incomplete plans of care these are high-volume denial drivers for HHAs. Medicare contractors’ denial reason lists show missing or inadequate certification as a top cause of episode denials.
-
The competitive RCM landscape for home health includes both specialty vendors and large RCM firms; key differentiators are episode-level compliance workflows, OASIS integration, and automation for certification/face-to-face tracking. Market interest in AI for RCM is growing because automation reduces manual review hours and helps prevent denials before they happen.
Takeaway: Home health agencies win when billing partners (a) enforce certification/recertification and face-to-face rules, (b) map clinical documentation to episode/HIPPS correctly, and (c) combine automation with clinical review to prevent denials.
How our AI-Powered Billing helps home health agencies
Your team needs accuracy and speed not hype. Here’s exactly how our AI helps:
-
Certification & face-to-face alerts (no more missed dates)
AI monitors timelines and pulls calendar/telehealth logs to produce an evidence bundle before the claim posts dramatically reducing certification-based denials. -
OASIS-to-HIPPS validation
ML models compare submitted OASIS items to historical OASIS→HIPPS mappings and flag inconsistencies (e.g., an OASIS answer that historically correlates with a different HIPPS level). That reduces underpayments and audit triggers. -
Predictive denial scoring & prioritization
AI assigns a recovery probability and expected value to each denial; your A/R team works highest-impact items first, shortening days-to-pay. -
Automated document extraction & claim bundle assembly
The system pulls face-to-face notes, physician certs, OASIS snapshots, and visit notes into a single claim packet for appeals or medical review responses saving hours of manual prep. -
Policy surveillance & rule updates
AI agents scan CMS HH PPS updates and contractor medical review guidance and propose scrub-rule changes so your claims reflect current policy (helpful given frequent HH PPS adjustments).
Bottom line: AI handles repetitive, time-sensitive checks and surfaces exceptions for clinical staff to review faster, more accurate billing without removing clinician oversight.
Quick Helpful Answers
- 01
- 02
- 03
- 04
- 05
