Home Specialties Home Health Billing Services
30-day PDGM episodes
case-mix & documentation
MA & episodic plans
on episodes marked paid
Our Home Health Billing Services Cover the Full Revenue Cycle
We manage the billing work around every 30-day payment period, from admission readiness and NOA submission through claims, payment posting, denials, and underpayment recovery.
Admission & NOA
Eligibility checks, payer requirements, NOA submission, authorization review, and admission readiness.
PDGM, OASIS & Episode Tracking
OASIS coordination, PDGM grouping, 30-day period tracking, LUPA monitoring, and recertification support.
Claims & Payment
Claim preparation and submission, payer follow-up, payment posting, and expected vs. actual reimbursement review.
Denials & Recovery
Denial management, appeals, aging A/R follow-up, corrected claims, and underpayment recovery.
Your 'Paid' Episodes Are Still Underpaid by 4–8%
Ask any home health agency about revenue-cycle pain and you'll hear OASIS accuracy, case-mix optimization, and audit risk. Real problems- the loud ones. Not the most expensive.
The most expensive one clears cleanly and posts as paid: an episode dropped to LUPA, a case-mix group quietly downgraded, or a payment trimmed because of a timing miss.
Across the 31 home health revenue cycles we've analyzed, an average of 4.2–8.1% of gross revenue is withheld this way. On an $8M agency, that's $336K–$648K every year and it compounds episode after episode.
The 4.2–8.1% range reflects OneMed's analysis of multiple home health revenue cycles. Actual recoverable revenue depends on payer mix, documentation quality, case mix, and operational workflow.
One Missed Visit Drops You to the LUPA Rate
Under PDGM, an episode pays the full case-mix rate only if it meets the visit threshold. Miss it often by a single visit and the payment doesn't shrink a little; it drops to a per-visit LUPA rate. Same patient, same 30 days, a fraction of the payment.
| The 30-day episode | What it should pay | What actually paid | The silent shortfall |
|---|---|---|---|
| Case-mix rate met with 6 visits | Full episode | Full episode | — |
| 5 visits — one short of threshold | Full case-mix rate | LUPA, per-visit | Episode value |
| OASIS understates acuity | Higher case-mix group | Lower group | Group difference |
| Recert signed one day late | Full episode | Reduced / reworked | Timing reduction |
Illustrative of common episode-level reductions; thresholds, LUPA rates, and case-mix values are set by CMS and change.
5 Ways Your Episodes Are Getting Underpaid.
Home health billing is a regulatory maze of PDGM case-mix, OASIS, and episode-timing rules. These are the underpayment patterns we find most often, on episodes that already say "paid."
LUPA visit-threshold trigger
PDGM pays the full case-mix rate only when the episode meets the visit threshold, often 6 visits. Provide fewer and Medicare pays a per-visit LUPA rate that can be a fraction of the case-mix amount. One missed or undocumented visit flips the whole episode.
OASIS case-mix downgrade
The OASIS assessment determines the case-mix group and payment. When it misses the patient's true clinical picture, the episode is assigned to a lower-paying group.
Homebound documentation reduction
Medicare requires documented homebound status. Missing or incomplete physician documentation can reduce payment or require expensive rebilling.
Plan-of-care recertification timing
Every episode must be recertified within the required timeframe. Even a one-day delay can trigger payment reductions or rework.
Nursing-visit (NRS) requirement failure
Episodes without at least one qualifying nursing visit become non-payable, creating denials, delayed cash flow, and unnecessary rework.
One Missed Visit Can Cost You $600 a Case.
PDGM pays the full case-mix rate only if the episode meets the visit threshold, often 6 visits. Provide only 5 visits, and the episode isn't paid a little less; it's paid at a per-visit LUPA rate that can be a fraction of the full case-mix amount.
The thresholds and payment rates are published by CMS. You can compare every LUPA episode against visit counts, case-mix groups, and reimbursement to uncover revenue that appears correctly paid, but isn't.
Illustrative figures only. LUPA visit thresholds vary by case-mix group, and payment rates change with CMS updates. Confirm current PDGM thresholds and reimbursement schedules. Actual exposure depends on your agency's case-mix distribution.
Your Team Isn't Watching for This
Your team is focused on OASIS completion, clinical compliance, and day-to-day operations while LUPA exposure, case-mix changes, and underpaid episodes can go unnoticed.
The “Paid Means Paid” Blind Spot
Once an episode posts as paid, it often leaves the work queue. We compare expected reimbursement with what the payer actually paid to catch underpayments that might otherwise be missed.
LUPA Risk Goes Untracked
We monitor visit utilization throughout the 30-day payment period so episodes approaching the LUPA threshold are identified before the period closes.
Case-Mix Changes Go Unchecked
We compare the paid case-mix group with OASIS and coding information to flag reimbursement changes or downgrades that need review.
Our recovery method
We work inside your existing home health software, review OASIS and episode records, and handle payer follow-up without disrupting your current workflow.
Identify the Revenue Gap
We compare expected reimbursement with the actual payment and flag LUPA losses, case-mix downgrades, denials, and other payment discrepancies.
Validate the Episode
Our reviewers check OASIS, coding, visit utilization, documentation, and payer requirements to confirm what the episode should have been paid.
Correct and Recover
We submit corrected claims, appeals, or supporting documentation and follow up with the payer until the payment issue is resolved.
Reconcile the Payment
We verify the corrected reimbursement, post the payment, and track recurring payer or workflow issues so the same revenue loss does not keep happening.
We've Recovered $1.89M From Underpaid Episodes
We don't rely on hypothetical math or isolated stories. We aggregated the anonymized data from every home health revenue cycle we audited over the last 18 months, here's the pattern it exposed.
home health revenue cycles audited
episodes audited
recovered for clients
recovery rate on appeals
Of that $1.89M, here's where it had been hiding. The LUPA cliff is the single biggest leak, because one missed visit can halve an episode.
| Underpayment pattern | Share of recovered value |
|---|---|
| LUPA visit-threshold triggers | 31% |
| Nursing-visit (NRS) requirement failures | 24% |
| Homebound status denials | 19% |
| Plan-of-care recertification timing | 16% |
| OASIS case-mix downgrades | 10% |
Aggregated across OneMed home health underpayment audits over the trailing 18 months ($2.14M identified, $1.89M recovered). Individual results vary by payer, documentation, and case mix.