Effective RCM in home care: Navigating regulatory requirements and reducing claim rejections

In the complex landscape of home-based care, effective Revenue Cycle Management (RCM) is essential for managing claims, tracking payments, and ensuring financial stability. Given the increasing regulatory requirements and challenges facing home care providers, a robust RCM system can have a meaningful impact on your business.  

In an episode of AlayaCare’s Home Health 360 podcast, host Erin Vallier spoke with industry expert Alik Kassner, co-managing partner at Alpine Homecare, who highlighted the critical role of a well-organized RCM process in navigating regulatory changes and claim rejection complexities. Listen to the full episode below:

To expand on Alik’s insights and best practices for home care RCM mentioned in the episode, let’s take a deeper dive to explore:

• The challenges of Medicaid claim rejections and federal and state regulatory requirements and how they impact an agency’s RCM process 
• Solutions for an effective RCM process 
• Examples of our recommended tech solutions to combat these challenges and enhance your RCM 
• Our on-demand webinar, which covers important aspects of RCM solutions in home-based care 

The impact of claim rejections and regulatory requirements on RCM processes

1. Rising Medicaid claim rejections causing a financial strain

Home care providers are experiencing a surge in claim rejections, which can significantly affect their RCM processes.  

Over time, claim rejections have increased significantly, highlighting the critical need for a robust system to monitor and resubmit claims effectively. According to a survey of hospitals, health systems, and post-acute care providers conducted by Premier, Inc, providers wasted $106 billion in 2022, overturning claims denials, demonstrating the financial strain caused by rejections. The rise in claim rejections can be attributed to various factors, including incomplete or incorrect documentation, coding errors, and compliance with regulations. Claims can be rejected for multiple reasons, such as missing or inaccurate documentation, non-compliance with electronic visit verification (EVV) requirements, and issues related to client eligibility.    

“There’s so much more, so many more reasons nowadays why your claims could get rejected. We’ve seen the introduction of electronic visit verification. If something is missing in your things, it immediately impacts your revenue cycle and claims. You won’t get paid.”

Alik Kassner, co-managing partner at Alpine Homecare, Episode 65 of the Home Health 360 Podcast. 

2. Staying on top of regulatory changes and requirements

Regulatory changes add another layer of complexity to home-based care RCM. These changes often require agencies to adapt quickly to new rules and processes. For instance, denied claims for missing EVV data is a significant challenge. Providers must ensure that all required EVV data is accurately captured and submitted to avoid rejections.    

Another challenge with regulations is Medicaid redeterminations. In the podcast, Alik explained how in Colorado, Medicaid redeterminations resumed after the pandemic. However, due to county staffing shortages, many claims were not processed in a timely manner, resulting in the automatic disenrollment of eligible clients. Additionally, introducing a new care and case management (CCM) system and a federal mandate for case management redesign further complicated the process, causing delays and increasing the risk of claim rejections.  

FAQs for Electronic Visit Verification (EVV)

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A robust software system can help implement effective RCM processes

Home-based care agencies need the right technology and tools to support their RCM processes and address regulatory challenges effectively. A comprehensive claims management system can significantly reduce claim rejections while ensuring compliance with federal and state regulations. It also centralizes all necessary information and data, allowing agencies to stay current with regulatory changes. It can review claims for accuracy and completeness before submission, reducing the likelihood of rejection. Automation further streamlines the process, improves efficiency, and reduces administrative burdens by handling repetitive tasks and providing real-time insights into claim statuses.  

Additionally, a system with EVV capabilities can help maintain compliance with regulatory requirements and enhance the reliability of claim submissions. It ensures accurate and verifiable service delivery records, which helps prevent discrepancies and further reduces the risk of claim rejections.  

“You need the technology to support your regular and team efforts. If you cannot track what you’re doing with all these appeals and redeterminations, if you cannot resubmit repeatedly and easily once you’ve got Medicaid and the PAR restored, and if you can’t track and forecast the effects of it all, then you’re not going to be very successful. You’ll be flying blind and won’t know if you have enough money to make payroll. So having a good system is key.”

Alik Kassner, co-managing partner at Alpine Homecare, Episode 65 of the Home Health 360 Podcast. 

Effective technology, such as AlayaCare cloud-based software platform, simplifies billing, making it easier to manage large volumes of claims and ensure timely payments, ultimately sustaining quality and financial stability despite external pressures. 

Here are examples of our recommended software features of the AlayaCare platform that can help providers address these challenges:  

1. AlayaCare’s Coordination of Benefits (COB) to reduce the risk of claim denials.  

The system streamlines the processing of secondary insurance claims by simplifying secondary insurance billing, eliminating the need for manual claim adjustments. It ensures a seamless process by maintaining a transparent and comprehensive audit trail at every step. Additionally, the system automatically captures and transmits occurrence and reason codes to secondary insurance, reducing the risk of denials.   

Related content: 4 ways First Day Homecare optimizes secondary billing processes with AlayaCare’s Coordination of Benefits 

2. AlayaCare’s Electronic Visit Verification (EVV) tool simplifies tracking and provides federal and state-required data for claims   

The system utilizes smartphone GPS data to ensure compliance with federal and state requirements and provide accurate, audit-friendly time and attendance tracking. It is designed to enhance efficiency by streamlining processes by integrating telephony and GPS mobile app features. AlayaCare’s EVV tool benefits caregivers and agencies by making tracking tasks more manageable and efficient.   

Related content: EVV unlocked: The truth about the Choice Model & the billing aggregator myth 

3. AlayaCare’s Eligibility Management Suite to automate client Medicaid eligibility status tracking to reduce the risk of claim denials

The system features automated eligibility status tracking and automatically retrieves, verifies, and displays clients’ Medicaid eligibility status through daily overnight monitoring. With this feature, you can automatically retrieve, verify, and display client Medicaid eligibility status on the Client Profile, along with daily overnight monitoring. It can detect changes as they happen, going beyond monthly or semi-monthly updates. The feature automatically sends email notifications for changes to ensure your teams stay informed about eligibility status. 

Gain comprehensive visibility into:  

•  New client intakes  
•  Any changes in coverage  
•  Certification/recertification dates  
•  Expired eligibilities  
•  Any changes in eligibility status  
•  Work through a queue to review and acknowledge these changes

Disclaimer: This feature is only available in certain states in the United States. Please contact us if you’d like more information.

Boost your RCM: 4 ways home care software can improve billing and payroll

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In today’s complex regulatory environment, having a robust software system for RCM is crucial for the long-term success of home care agencies. A comprehensive system enables efficient claim submissions, accurate tracking of payments, and timely resubmissions, ultimately ensuring financial stability.  

“If you’re not able to track all that, you’re just going to be bleeding cash, and you’re not going to be very successful long-term. Revenue cycle management is key, especially nowadays.”

Alik Kassner, co-managing partner at Alpine Homecare, Episode 65 of the Home Health 360 Podcast. 

ON-DEMAND WEBINAR 

Overcoming top RCM challenges in home-based care 

Watch as RCM industry experts discuss: 

•  The cost of rejected claims—not getting it right the first time—staff costs, cost to make corrections, and the cost of delayed payment.  
• The effects of EVV compliance on RCM, ways to reduce the risk of penalties, and steps to provide a complete audit trail.  
• How to verify eligibility and track utilization to avoid both overserving and underserving clients.  
• Strategies to align billing and financial processes with government regulations.