Home Health revenue cycle management
Home health revenue hinges on OASIS accuracy, PDGM periods and authorizations. AI agents verify coverage, track auths and periods, and keep claims and RAPs/final claims flowing end to end.
Home health billing is uniquely complex: OASIS-driven PDGM periods, LUPA thresholds, authorizations, and the RAP-to-final-claim cycle. MedXFlow verifies eligibility, tracks authorizations and 30-day periods, supports coding, and runs claims, posting and denials so cash does not stall between periods.
Periods & authorization
- PDGM period tracking - Tracks 30-day PDGM periods and LUPA visit thresholds to avoid underpayment.
- Authorization management - Submits and tracks payer authorizations across the episode.
- OASIS-linked documentation prompts - Prompts for the documentation that supports the billed period.
Eligibility & benefits
- Coverage & benefit verification - Verifies home-health coverage and benefit periods before care.
- Medicare & MA plan handling - Handles Medicare and Medicare Advantage home-health rules.
Claims cycle
- RAP & final claim handling - Manages the notice-of-admission and final-claim cycle on time.
- Claim status follow-up - Polls status and chases stuck claims automatically.
Posting & denials
- Payment posting - Auto-posts ERAs and reconciles by period.
- Denial management - Works authorization and documentation denials by root cause.
What you get
- PDGM periods and LUPA thresholds handled correctly
- Authorizations tracked across the episode
- RAP and final claims filed on time
- Fewer documentation-driven denials
Frequently asked questions
What is PDGM in home health billing?
PDGM (Patient-Driven Groupings Model) is Medicare's home-health payment model. It pays by 30-day periods, with case-mix driven by patient characteristics from the OASIS assessment rather than therapy volume, so OASIS accuracy directly drives reimbursement.
What is a LUPA?
A Low Utilization Payment Adjustment applies when visits in a 30-day period fall below the threshold for that case-mix group. The period is then paid per visit instead of the full episode amount, which is a large revenue difference, so tracking visits against the threshold matters.
What is the RAP or Notice of Admission?
It is the notice filed at the start of care that establishes the period with Medicare, followed later by the final claim. Filing it late carries a payment penalty, so timely submission protects the full period payment.
Why are home health claims denied?
Common causes are documentation that does not support the billed case-mix, missing or expired authorizations on Medicare Advantage plans, eligibility or benefit-period issues, and timing problems with the notice or final claim.