Originating largely during the COVID-19 pandemic, acute hospital at home programs are now widespread nationwide, showing low mortality, high patient satisfaction, and solid savings of 30% or more per admission compared to traditional inpatient care. The acute hospital at home movement continues to gain traction with 400 hospitals approved to provide Medicare patients with inpatient-level home care. However, despite this growth, revenue cycle management questions remain:
• What will happen once the CMS hospital at home waiver expires on September 30, 2025? This waiver recognizes acute hospital at home care as a virtual hospital unit and waives the hospital requirement for 24-hour onsite nursing.
• What about Medicaid and commercial payers—will they all eventually pay for acute hospital at home services?
•Will the industry agree on consistent billing codes and acute hospital at home billing guidelines for these services? Doing so would help streamline complex prior authorization requirements and patient cost-sharing ambiguities.
“Organizations are still in the learning phase in terms of how to deploy acute hospital at home programs effectively,” says Calvin Gold, operations manager at Global Healthcare Resource. “Eventually, there will be more standardization of charges based on care that’s typically provided at home.”
Effective revenue cycle management for acute hospital at home programs
For now, Gold shares several hospital at home billing guidelines to help improve revenue cycle management efficiency and accuracy.
1. Verify eligibility carefully. “Some payer policies may not pay for hospital at home services,” says Gold. “Organizations must understand based on the patient’s plan and the hospital’s contract with the insurance company what services require prior authorization.”
2. Be mindful of "out of plan" care. Most of the denials hospitals experience are because they provide unauthorized treatments when care plans change or when patients require additional services,” explains Gold.
For example, a patient may need a registered nurse to come to the home more frequently than anticipated to assess their clinical status. Or a patient receiving at-home chemotherapy under the care of an oncologist falls in their home and requires follow-up care related to the fall. In both scenarios, medical necessity is key, and in some cases, a separate (additional) prior authorization may be necessary. For example, the oncologist may need to refer the patient to a different physician for at-home care related to the fall, the organization may need to submit a new care plan, and the organization may need to obtain a new prior authorization. When proactive strategies are ineffective, having a solid process in place for first-and second-level appeals helps prevent revenue leakage, adds Gold.
3. Report the correct codes. For example, payer-specific hospital at home billing guidelines may require S codes for skilled nursing services in acute hospital at home programs while others may require G codes, says Gold. “It’s critical for organizations to monitor denials and rejections for at least 90 days and then make changes within the EMR to promote clean claims,” he adds. “This includes paying attention to procedure codes as well as revenue codes, place of service codes, and diagnosis codes.”
4. Respond to payer requests for additional documentation. In some cases, payers may require additional documentation of acute hospital at home services before payment. “Payers have every right to ask for this, and providers must submit information within the specified timeframe,” says Gold.
5. Track and monitor key performance indicators (KPI). While there are no industry standards for acute hospital at home metrics, Gold says it’s important for organizations to create revenue cycle KPI baselines and then compare performance to them over time. The following KPIs are particularly important for acute hospital at home programs and may even help with payer contract negotiations:
Partnering with the right revenue cycle management vendor. As healthcare organizations look ahead to the potential expansion of acute hospital at home programs, having the right revenue cycle management vendor in place can help tremendously. The partnership can simplify eligibility verification for acute hospital at home services, appeal acute hospital at home denials, ensure proper payer setup to comply with hospital at home billing guidelines, provide patient education, and more.