8 most common billing mistakes in home health and hospice

Our RCM team supports over 150 agencies nationwide. These are the recurring billing challenges they have in common. And they’re costing organizations time and money.

1. Medicare Humana down-coding claims

The problem:
Medicare Humana Advantage plans are reducing payments by down-coding claims. That means services are misclassified at a lower complexity level, even if you coded everything correctly. Without comparing your expected and actual reimbursement, these shortfalls can go unnoticed.

The fix:
Review your remittance advice closely. If the payment doesn’t match what you expected, appeal it with proper documentation. Consistent checks are essential to avoid lost revenue.

2. Blue Cross Blue Shield G-code confusion

The problem:
BCBS representatives often provide standard G-codes during authorization, but these codes may not match your contracted codes. Since the reps don’t have access to your agency’s specific agreement, this leads to claim denials or underpayments. Appeals are now frequently rejected, leaving you with unrecoverable losses.

The fix:
Train your intake and billing services staff to use the codes outlined in your actual contract. Verbal authorizations are not enough. This small shift can prevent denials before they start.

3. Medicare BCBS claims denials from NOA issues

The problem:
Some Medicare Advantage BCBS plans aren’t linking the Notice of Admission (NOA) with final claims, even when the NOA was submitted correctly. This causes claims to be denied or returned with incorrect error messages.

The fix:
Watch for denial codes that suggest a missing or invalid NOA. If the issue appears, request a manual review and provide proof of submission. Clear tracking helps resolve these quickly.

4. Cigna remittance portal outages

The problem:
Cigna’s online portal has been unreliable, preventing access to remittance details and recoupment letters. Without this information, your team may miss payment discrepancies or payor takebacks.

The fix:
Cigna is aware of this issue. Until the portal is fully functional, track claims manually and flag any discrepancies. Stay vigilant with account reconciliation to avoid compliance and cash flow issues.

5. MBI mismatches after the Change Healthcare breach

The problem:
After the 2024 data breach, Medicare reissued many MBIs. While patient records were updated, corresponding OASIS forms often were not. The mismatch causes claims to reject or terminate mid-admission.

The fix:
When updating MBIs, ensure the corresponding OASIS is updated and submitted as corrected OASIS. Run frequent eligibility checks to catch mismatches early and avoid delays in medical billing.

6. TRICARE region realignment

The problem:
As of January 1, 2025, TRICARE reassigned six states (Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin) from the East to the West Region. Many agencies are still billing the wrong payor or have not completed re-enrollment. Incorrect submissions are rejected by clearinghouses or denied by payors.

The fix:
If you operate in any of these six states, confirm you are enrolled with TRICARE West and using the correct payor IDs. This is a critical update for your billing and coding team.

7. TRICARE bundled versus unbundled billing

The problem:
TRICARE authorizations alternate between bundled (episodic) and unbundled (fee for service) every 120 days. If your team doesn’t discharge and readmit patients during the switch, claims will be denied or paid incorrectly.

The fix:
Always verify the service model during reauthorization. Make sure patients are discharged and re-entered when the billing model changes. Keep internal workflows aligned to avoid missteps.

8. Medicare DDE latency and RTP issues

The problem:
The Medicare Direct Data Entry (DDE) system is experiencing latency issues. Claims submitted manually are being rejected with Reason Code 30993, which indicates that the MBI crosswalk is unavailable. This leads to returned or duplicate claims.

The fix:
Resubmit affected claims and monitor for duplication. Stay up to date by subscribing to issue logs from your MAC. Frequent monitoring can prevent billing problems from spiraling.