Denied Claims Often Trace Back to Workflow Issues, Not Billing

Most homecare agencies see payment denials and delays as billing issues. It’s a natural assumption, after all — if a billing claim is rejected, the problem must be in the billing department. Agencies may put time and money into billing-specific software and outside consultants, yet still face denials if workflows aren’t aligned to support those efforts. But when the right processes for improvement are in place, their investments are more likely to deliver strong results and a meaningful return.

A billing issue flagged on an accounts receivable report is likely indicative of deeper problems rooted in areas like scheduling, care delivery, or authorization management. These breakdowns start days or weeks before a claim is ever submitted. Fixing them requires upstream visibility, not just downstream billing cleanup.

Billing Issues Often Originate Outside Billing Departments

When revenue cycles stall, turning to billers for a solution is akin to requesting roadside assistance after a hydroplaning incident. It’s a helpful part of the recovery effort but not a substitute for safer operation and navigation beforehand. Preventing breakdowns at the source is always preferable to addressing the fallout. 

Roughly 82% of Medicaid claim denials and improper payments are driven by administrative, eligibility, and documentation issues, rather than billing errors. Common denial triggers include:

• Mismatched visit documentation: Caregivers clocking in with codes that don’t match the authorization
• Expired or overused authorizations: Providing care after an authorization ends or exceeding the approved units
• Missing EVV data: Failing to capture the “Big Six” data points required by the 21st Century Cures Act

Agencies that treat these as billing errors are treating the symptoms, not the cause — and their billing teams may end up cleaning up messes instead of focusing on timely, accurate claim submissions and reimbursement optimization. 

Workflow Gaps Create Revenue Leaks

Disjointed systems put scheduling, care delivery, and billing data in silos, which creates visibility gaps where errors can hide until it’s too late. Consider the factors that can contribute to denied claims:

• Intake/authorization: A coordinator enters an authorization manually but makes a typo on the service code.
• Scheduling: A scheduler assigns a shift that exceeds the weekly authorized hours because the system doesn’t flag the overage.
• Care delivery: A caregiver forgets to record a mandatory duty task or some clinical information.
• Billing: The biller batches the claim. Because there are no pre-claim checks, the error goes unnoticed.

Any of these may trigger a payer’s denial of the claim 30 days later. However, the mistake stems from the workflow, not the billing process. The lack of connectivity between authorization, the schedule, and point of care mean no one is alerted to the problem when it’s still fixable.

Go from Reaction to Prevention and Avoid Clean-Up Costs

Relying on billing teams to manually catch errors is a poor strategy, which leads to:

• Revenue leakage: Claims are never resubmitted because the timely filing window has passed.
• Cash flow barriers: Agencies wait 60 days or more for payment on services delivered months ago.
• Staff burnout: Administrative staff spends hours on the phone with payers instead of managing high-level operations

Agencies must move upstream to stop denials, using a system that validates data throughout the process — not just at the end. Leveraging integrated homecare management software to support every phase can make a world of difference. Providers with this technology can connect data from payers, providers, and caregivers in a single system to prevent the creation of non-compliant claims from the outset. 

Effective workflow management acts as a safety net by providing intelligent scheduling, real-time EVV compliance checks that alert caregivers of missed clock-ins and tasks, and pre-billing scrubs using automated tools that scan for missing fields, formatting errors, and eligibility issues. HHAeXchange’s platform enables providers to shift their focus from “better billing” to “better workflows.” When you stop chasing denials and start preventing them, the care you deliver will turn into the revenue you deserve.
Learn how HHAeXchange eliminates the slow payments and errors holding your homecare agency back so you can get paid faster.