In the home health industry, every denied claim represents lost revenue, delayed payments, and potential disruptions in patient care. At Konnext Solutions, we specialize in helping agencies reduce their denial rate, protect cash flow, and stay compliant with Medicare billing requirements.

For home health providers, an acceptable denial rate is around 3%, anything higher is a red flag that billing and documentation processes need improvement. Understanding the top causes of home health billing denials (especially under Medicare) is the first step toward fixing and preventing them.

Top Reasons Medicare Denies Home Health Claims

1. Medicare Eligibility Issues

Medicare covers home health services only if the patient meets strict criteria:

• Must be homebound (leaving home requires considerable effort and is infrequent).
• Must require intermittent skilled nursing or therapy services.
• Common eligibility denials occur when documentation fails to support medical necessity, or when services exceed Medicare’s allowable limits (generally more than 28–35 nursing hours per week).Example: “Skilled nursing services were not medically necessary” remains Medicare’s #1 home health denial reason.

2. Documentation Errors

Medicare requires a valid physician certification and plan of care for every home health episode. Missing, incomplete, or invalid documentation leads to automatic denials.

Frequent documentation mistakes:

• No physician signature on plan of care.
• Signatures without dates or illegible signatures.
• Missing or invalid orders.

Even small paperwork errors can make the entire episode non-billable.

3. Face-to-Face (F2F) Encounter Issues

The face-to-face encounter requirement is one of the most common denial triggers. Medicare mandates that:

• A qualified provider meets the patient in person within 90 days before or 30 days after start of care.
• The visit must relate directly to the need for home health.
• The actual progress note (not just an attestation form) must be submitted.

Late, missing, or irrelevant F2F documentation will cause Medicare to deny the claim.

4. Incorrect Coding

Incorrect or mismatched diagnosis (ICD‑10), HIPPS, or HCPCS codes can lead to rejections or denials.
Examples include:

• Codes that don’t match the patient’s medical record.
• Missing modifiers.
• Invalid codes for covered home health services.

Accurate coding is essential for both compliance and payment.

5. Timely Filing Issues

Medicare requires home health claims to be filed within 12 months of the date of service. Missing this deadline results in permanent denial.

• Other payers may have deadlines as short as 90–180 days.
• Internal delays or uncorrected rejections can push claims past filing limits.

Common Medicare Denial Codes

• 5HN18 – Skilled nursing not medically necessary.
• 5HC09 – Initial certification invalid; subsequent episodes denied.
• 5HC01 / 5FF2F – Face-to-face encounter missing/incomplete/untimely.
• 5HY01 – Therapy not reasonable or necessary.
• 56900 – Medical records not received by deadline (ADR).

Understanding these codes helps agencies quickly identify and fix root causes.

How to Reduce and Prevent Home Health Billing Denials

1. Conduct Internal Audits

• Pre-billing chart reviews for eligibility, documentation, and coding.
• Spot patterns in past denials and address them proactively.

2. Use Billing Software and Claim Scrubbers

• Flag missing data, coding errors, and expired certifications before submission.
• Track timely filing deadlines and denial trends in real time.

3. Train Your Staff Continuously

• Regular education on Medicare rules, PDGM coding, and documentation standards.
• Emphasize that small mistakes (like missing dates) can cost thousands.

How to Appeal a Medicare Denial

1. Identify the denial reason – Review denial code and reason.
2. Correct obvious errors – Fix typos, update missing info, or resubmit with the right documents.
3. Gather evidence – Include medical records, signed orders, F2F notes, etc.
4. File a Redetermination – Submit to your MAC within 120 days of denial
5. Escalate if needed – Reconsideration, ALJ hearing, Appeals Council, Federal Court.
6. Track your appeals – Maintain a denials log and follow up until resolved.

Why Partner With Konnext Solutions

We help home health agencies:

• Lower denial rates below the 3% industry benchmark.
• Improve claim accuracy with expert audits.
• Accelerate reimbursement and protect cash flow.
• Stay compliant with Medicare billing

📞 Contact Konnext Solutions Today
Let us manage your billing and denial prevention so you can focus on patient care. Call 551‑261‑3456 or email info@konnextsolutions.com to schedule a free consultation.