The authorization-to-claim gap: where home-care revenue quietly disappears.
Between what a payer authorized and what finally gets paid sit four numbers that should reconcile and usually do not.
The four numbers
Authorized is the payer-approved ceiling. Units, dates, codes, and rate. It is the maximum recoverable dollars for the period, and no downstream number can honestly exceed it.
Delivered is the EVV-verified visit. What actually happened on the ground, captured with the six required data elements.
Billed is the claim submitted, with its own code, modifier, unit, and rate combination.
Paid is the remittance line the payer returned, the only number that turns into cash.
Timely filing sets the clock
Under 42 CFR 447.45 the federal outer limit is 12 months from the date of service. States set shorter, commonly 90, 120, or 180 days. Managed-care plans tighter still.
The gap has to be closed inside the shortest applicable window, because past that window the money is gone regardless of whether the claim would have been correct.
The shapes the gap takes
Unbilled authorized hours. Care was delivered inside the authorization and no claim was ever built.
Over-authorization overage. Hours delivered beyond the authorized ceiling. That overage is compliance exposure, not recoverable revenue, and it never becomes cash.
Authorization drift. The billed code, modifier, or unit count wandered off the auth over time and the claim no longer matches.
Silent underpayments. Paid below the authorized rate. The claim adjudicates as approved and pays low.
Lapsed-authorization denials. Care delivered after the auth expired, denied on eligibility grounds.
How to close it
Reconcile the four numbers continuously on each closed period, not once a year in an audit. The correctable gaps have short windows, and reconciliation after the window is only a lesson.
A working close compares authorized to delivered to billed to paid on one closed period, flags every mismatch with a reason, and separates the recoverable dollars from the exposure that is not.
Plain answers, on the record.
Collect is money you never captured. Cover is money a payer can still take back.
Reeve reports the two separately and never adds them together, because only one of them is yours to go and get. The Margin Review reads both on your own export and costs nothing.
One pass over your own export, in your browser. The findings are yours to keep, with no obligation.
The recovery lane. Care you delivered and never billed, units short of what was authorized, lines paid under the published rate.
Everything in Collect, plus the exposure lane. Retired codes, authorizations at the end of their period, care delivered past what was approved.
Month to month, no annual contract. Read-only in every tier. Run the free review.
See the gap on a closed period.
The Margin Review reconciles authorized, delivered, billed, and paid for one closed period and returns a ranked list of recoverable dollars with a reason on each line.