In the home health industry, eligibility issues are the #1 reason for claim rejections. This means that if you don't properly verify a patient's eligibility, there's a good chance that your claim will be denied.

In this blog post, SimiTree’s Lynn Labarta, VP of Post Acute Revenue Cycle Management, breaks down the importance of verifying patient eligibility and the consequences of failing to verify and provides tips on how to do it correctly.

If you are interested in downloading our free cheat sheet that goes deeper into the details that you need on insurance eligibility, simply visit this page and hit ‘download now’.

The Importance of Verifying Eligibility: Patients Receiving the Care They Need

Verifying patient eligibility is important for several reasons. First and foremost, you are doing right by the patient.

When you verify a patient's eligibility, you are essentially confirming that they are covered for the services they need. This helps to ensure that they are receiving the care they need and that your agency is not providing care that is not covered.

The Importance of Verifying Eligibility: Preventing Revenue Loss and Maintaining Reputation

Verifying eligibility will also help to protect your agency from financial losses. If you provide care to a patient who is not eligible, you may not be reimbursed for the services you provided. This can lead to financial losses for your agency and ultimately hurt your agency in the short term and in the long term. This is avoidable!

Additionally, whether you are a startup home health agency or celebrating 20 years in business, verifying eligibility will help to improve your agency's reputation. If you are facing eligibility issues and claim rejections, you are essentially demonstrating to patients, payers, and your referral source that you are not a reputable agency that ensures that patients are eligible for the services they need. This leads to financial stress, referral and intake issues, and more. (This is also avoidable!)

Consequences of Failing to Verify Eligibility

If you fail to verify a patient's eligibility, your home health agency may face these consequences:

  • The patient may not receive the care they need.
  • Your agency may not be reimbursed for the services you provided.
  • Your agency may be out of compliance with regulatory requirements.
  • Your agency's reputation may be damaged.

How to Avoid Eligibility Issues: 4 Ways to Ensure Your Patients Are Eligible for Insurance Reimbursement

  1. Make sure the patient's policy is effective. This may seem like a no-brainer, but it's important to double-check the policy start date to make sure the patient is covered for the services they need.
  2. Determine if the patient has in-network or out-of-network benefits. If the patient has in-network benefits, you'll need to make sure that your agency is contracted with their insurance company. If the patient has out-of-network benefits, you'll still be able to provide care, but you may not be reimbursed as much. You can learn more about this in our free Insurance Eligibility Instructions download.
  3. Find out if any authorizations are required. Some insurance companies require prior authorizations before they approve home health services. Make sure you find out if this is the case for the patient's insurance company and get the authorizations you need before you start providing care.
  4. Determine the patient's deductible and copays. Patients may be responsible for paying a portion of the cost of their home health care. Make sure you know how much the patient will have to pay in deductibles and copays so that you can bill them accordingly.

By following these tips, you can help to avoid costly insurance eligibility issues and ensure that your home health claims are paid.

How SimiTree Can Help

Download our insurance eligibility instructions sheet for free.

To accurately conduct eligibility for a home health non-traditional Medicare patient, meaning a patient that has private insurance, commercial insurance, Medicare Advantage, Medicaid, VA, etc., we've created a cheat sheet that walks you through the questions you need to ask the insurance company. You can download the cheat sheet here.

If you have any questions about eligibility or home health billing, please don't hesitate to contact us. SimiTree can help you avoid eligibility issues and ensure that your home health claims are paid. We offer a variety of services to help you with your revenue cycle management, including:

  • Eligibility verification
  • Claim filing
  • Appeals
  • Collections

We're here to help you succeed. Fill out a contact for below to talk to an expert today and visit our website to more about SimiTree’s revenue cycle management solutions.


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Let's work together to improve the health of your organization. At SimiTree, we balance financial expertise and clinical excellence to help our clients grow. How can we help you? Call us at 800.949.0388 or complete the form below.