run-billing-and-survey-readiness

name

run-billing-and-survey-readiness

description

Turn home-health documentation into paid, survey-proof claims by traversing the home-health decision tree (documentation completeness: OASIS / plan of care / visit notes → PDGM 30-day period billing: NOA + final claim, LUPA watch, comorbidity → Medicaid-waiver / private-pay per-unit billing → denial root-cause analysis → conditions-of-participation & survey-readiness checks), then return the completeness gate, the period claim, the denial fixes, and the CoP/survey-readiness gap list. Reach for this when the user asks 'bill this 30-day period', 'why are our claims denied?', 'is our documentation complete?', or 'would our charts pass a survey?'. Used by home-care-operations-specialist (primary) and home-health-agency-lead.

Skill: run-billing-and-survey-readiness

Invoked by: home-care-operations-specialist (primary — the documentation-to-claim run and the survey-readiness pass) and home-health-agency-lead (the CoP/survey posture and the PDGM billing implications of the payer mix).

When to invoke: "bill this 30-day period"; "why are our claims being denied?"; "is our documentation complete enough to bill?"; "check our LUPA risk"; "would our charts pass a survey?"; "map our gaps against the Conditions of Participation"; any "get paid and pass survey" question.

Output: the documentation-completeness gate + the PDGM 30-day period claim (or the Medicaid-waiver/private-pay claim) + the denial root-cause analysis & fix + the CoP/survey-readiness gap list — with the audit trail that survives review.

Procedure

1. Gate billing on documentation completeness — the documentation is the claim. Before any claim, confirm the record is complete and defensible: the OASIS assessment (accurate — it drives the PDGM case mix and the quality outcomes), the physician-ordered plan of care (signed, followed, updated), and the visit notes (skilled content, timely, matching the ordered frequency). Incomplete or late documentation is a denial and a citation — the completeness check is a precondition to billing, not a cleanup after.
2. Bill the PDGM 30-day period deliberately. Traverse the billing branch in ../../knowledge/home-health-care-decision-tree.md. Under PDGM the 30-day period is paid on clinical grouping, functional impairment level, admission source (community vs institutional), and timing (early vs late) — not visit count. Submit the NOA (Notice of Admission) on time (late NOA = payment reduction), then the final period claim. Watch the LUPA threshold (too few visits flips the period to per-visit payment) and apply comorbidity adjustments. (PDGM rates, weights, and NOA timing are volatile — retrieval date.)
3. Bill the non-Medicare paths against the authorization. Medicaid waiver / MCO — bill the authorized units per service type, with the EVV verification attached (no EVV, no payment). Private pay / LTC insurance — invoice the agreed hours/rate, per the agreement. Confirm each claim matches the authorization and the verified visits before submission.
4. Work denials by root cause, not one-off appeals. Group denials by source — eligibility (homebound/skilled-need), order/certification (missing/late signature, face-to-face), documentation (incomplete/late notes, OASIS errors), EVV (unverified/mismatched visits), timing (late NOA), or authorization (units exceeded). Fix the source so the denial doesn't recur; a rising denial rate in one bucket is a process defect, not a billing-clerk problem.
5. Run the survey-readiness pass against the Conditions of Participation. Check the operational record against the CoP the way a surveyor would: QAPI program active, patient rights honored, plan-of-care and physician-order compliance, OASIS accuracy, EVV completeness, visit-note timeliness, competency/supervision records, infection control, and complaint handling. Produce the gap list — the specific things a surveyor would cite — with the remediation for each. (CoP interpretive guidance is volatile — retrieval date.)
6. Make survey readiness a daily habit, not a scramble. The same completeness and CoP checks that gate billing are the ones a survey tests — run them continuously (the chart clean every day never needs a pre-survey cram). Tie the readiness pass to the billing run so the two reinforce each other.
7. State the payment/survey-risk conditions — the 1-2 facts that would deny payment or trigger a citation (e.g., "the NOA is late → automatic payment reduction for the period → tighten the NOA-submission SLA"; "OASIS coding doesn't match the visit documentation → case-mix and audit risk → reconcile before billing").

Worked example

User: "We've got a 30-day PDGM period to bill and our denial rate is climbing. Bill it and tell me what's wrong."

• Completeness gate: OASIS complete and internally consistent, plan of care signed, visit notes timely — one visit note is late → hold and correct before billing (a would-be denial caught pre-submission).
• PDGM period: community admission, medication-management clinical group, medium functional level, early period; NOA submitted on time; visit count is above the LUPA threshold → full period payment (not per-visit); comorbidity adjustment applied.
• Denial root cause: the climbing denials cluster in the EVV bucket — visits delivered but not verified/mismatched → fix the source (the same-day EVV exception procedure), not the appeals.
• Survey readiness: CoP pass finds a supervision-visit documentation gap (aide supervisory visits not consistently recorded) → remediate now, before it's a citation.
• Condition: if NOA submissions keep slipping late, the automatic payment reduction compounds → set and monitor an NOA-submission SLA.

Guardrails

• Documentation is the reimbursement — gate billing on OASIS/plan-of-care/visit-note completeness; if it isn't charted, it wasn't done and it won't be paid.
• PDGM is not visit-count billing — the 30-day period pays on clinical group, function, admission source, and timing; watch the LUPA threshold and submit the NOA on time (late NOA reduces payment).
• Medicaid/waiver claims need the EVV attached — no verification, no payment.
• Work denials by root cause (eligibility, order, documentation, EVV, timing, authorization) — fix the source so it doesn't recur.
• Survey readiness is a daily habit, not a scramble — run the CoP checks continuously and tie them to the billing run.
• Running the claim and the readiness pass is execution (the operations specialist); the CoP posture and quality/VBP strategy are policy (the home-health-agency-lead) — keep the seam clean; deep survey-remediation program design → regulatory-compliance.
• This is not hospital/physician-group RCM — that's medical-revenue-cycle; this plugin owns the home-health agency's billing and survey record.
• PDGM rates/weights, NOA timing, OASIS versions, and CoP interpretive guidance are volatile — carry a retrieval date and re-verify before billing or a survey. See ../../knowledge/home-health-care-patterns-2026.md. Not medical, legal, or reimbursement advice.