Reasons to Not Accept a Patient based on Eligibility Results

Low Allowables

  • Payer has a low “Allowed Rate” for payment of specific services.
  • Especially true for home health services with commercial payers regardless of contract status.
  • Some commercial payers may only “allow: $50 for an SN visit or even a PT visit.

High Cost Share

  • The patient bears high responsibility (out of pocket) for the home health services rendered.
  • High cost share means the patient’s policy has a high deductible, high co-insurance and in some cases a high co-pay.
  • When we return Plan Pays: 40%; Co-Insurance: 60%, this means the patient will be responsible for 60% of the allowed rate and the insurance will cover the other 40%.
  • From our example above: If the allowed rate is $50 for a PT visit and the patient has 60% Co-Insurance, the patient is responsible for $30 of the visit and the Insurance will pay $20. We all know PTs (and PTAs) cost more than $20 per visit.
  • Even when the insurance has a decent allowed rate, but the patient’s policy has high cost share built in, we will still recommend to not accept.
  • Example: Allowed rate for a PT visit is $100 and the patient has 60% co-insurance; patient is responsible for $60 and the Agency will receive $40 for the PT visit.

No HH Coverage

  • This means the patient has insurance, but the policy does not offer coverage for Home Health services.
  • The patient is responsible for 100% of the cost of services.
  • This can be Commercial Plans and Medicare Advantage plans.

Inactive Coverage

  • At the time Majestic Billing pulled eligibility using the agency provided data, the patient’s policy is inactive and therefore has no coverage.
  • When this happens, we provide our best efforts to determine if the patient may have other coverage.
  • Reach out to the patient or patient’s family to see if the patient switched Insurance Company.

Our recommendations to Accept or Not Accept patients is purely based on the facts that we uncover pulling eligibility. The Agency has every right to take any patient.