Home health agencies in the U.S. face a significant challenge with denied claims, especially under Medicare. A denied claim means the payer (like Medicare) refuses payment for services, which can disrupt cash flow and patient care.
An acceptable denial rate in home health is typically around 3% – anything higher signals problems in the billing process. Understanding why home health billing denials occur is the first step in preventing them.
This article examines the top reasons for home health denials (with a focus on Medicare), explains common Medicare denial codes, and offers professional strategies for preventing and appealing denied claims.
Top Reasons for Denied Claims in Home Health
When a home health claim is denied, it’s usually for one (or more) of a few common reasons. Below are the top reasons Medicare home health claims get denied, along with why they happen:
Medicare Eligibility Issues
Medicare has strict eligibility criteria for home health services. If a patient doesn’t meet “homebound” requirements or truly need intermittent skilled care, Medicare will deny the claim.
For example, claims are denied if documentation shows the patient was not actually homebound (e.g. the patient was noted to leave home frequently without considerable effort).
Failing to meet the intermittent care requirement can also trigger denials providing more nursing care hours than Medicare’s limits (generally more than 28–35 hours per week) or attempting daily long-term care without a clear end date violates Medicare’s coverage criteria.
In short, if the services are not medically necessary or the patient isn’t eligible for home health under Medicare’s rules, the claim will be denied. In fact, “skilled nursing services were not medically necessary” is consistently the #1 denial reason found in Medicare reviews
Documentation Errors
Incomplete or incorrect documentation is another major cause of home health denials. Medicare requires a valid physician certification and plan of care for every home health episode. If any required document is missing, unsigned, or invalid, payment will be refused.
In one recent analysis, 20% of denied home health claims were because the initial physician certification or plan of care was missing, incomplete, or invalid, causing the subsequent episode to be denied
Common documentation errors include:
1- A plan of care with no physician signature
2- signatures without dates,
3- Other omissions in required forms.
Even a seemingly minor paperwork detail can lead to denial. for instance, if the physician’s signature is not dated or is illegible, the certification is considered untimely/invalid and Medicare will deny the claim.
Home health agencies must ensure all documentation (orders, certifications, visit notes, etc.) is thorough, accurate, and meets Medicare’s requirements to avoid these denials.
Face-to-Face Encounter Issues
Face-to-face (F2F) encounter documentation is a notorious trouble spot in home health billing. It’s no secret that face-to-face documentation is one of the top reasons Medicare denies home health claims
Medicare requires that a qualified provider (usually the certifying physician or certain non-physician practitioners) meet the patient in person and document the encounter related to the need for home health.
This encounter must occur within 90 days before the start of care or 30 days after. If the F2F encounter isn’t properly documented and timed, the home health claim will be denied as an invalid certification.
Common F2F errors include failing to obtain any face-to-face note, obtaining it outside the required timeframe, or having an unrelated encounter note. Medicare will flag the claim because “the physician certification was invalid since the required face-to-face encounter was missing/incomplete/untimely.”
In many cases, agencies mistakenly submit only a F2F attestation form without the actual clinical progress note from the encounter, which is not sufficient and leads to denial. To avoid F2F-related denials, home health providers must ensure a timely, relevant face-to-face visit is performed and that the detailed encounter note (not just a form) is included in the documentation.
Incorrect Coding (CPT/HCPCS Errors)
Using the wrong billing codes or data on a claim is another frequent reason for denials or rejections. Every home health claim must have codes (diagnosis codes, procedure codes, etc.) that accurately reflect the patient’s condition and the services provided. Incorrect coding.
For example, if the diagnosis code on the claim doesn’t match the patient’s medical record, or if an invalid HCPCS/CPT code is used, can cause the claim to be rejected by the Medicare claims system or denied upon review.
Coding errors include mismatches in procedure codes, omitted modifiers, or the use of codes that are not covered for home health services. In home health, this might involve the HIPPS code or revenue codes derived from OASIS and diagnosis data.
Coding mistakes often result in automatic claim rejections (which prevent the claim from processing) or denials for medical necessity if the codes don’t align with coverage criteria. The bottom line: accuracy in coding is vital.
Timely Filing Issues
Medicare (and other payers) enforce strict, timely filing deadlines. If a home health claim is submitted late, beyond the allowed time window, it will be automatically denied, regardless of how valid the services were.
Medicare’s rule is that home health claims must be submitted within 12 months (1 calendar year) of the date of service. For example, if you provided care starting July 1, 2024, the claim needs to reach Medicare by July 1, 2025.
Missing this deadline results in an irreversible denial (unless a very limited exception applies). Many other insurers have even shorter deadlines (90 or 180 days). In practice, agencies sometimes miss filing deadlines due to internal delays or if a claim was returned for corrections and not resubmitted in time.
Late submissions are a preventable cause of lost revenue. One industry study found roughly 7% of claims get denied for timely filing lapses across healthcare.
In Medicare’s case, any claim filed after the one-year mark will be denied with no payment made. Home health providers must track billing dates closely (and also ensure required prior submissions like the Notice of Admission are timely) to avoid this pitfall.
