Home care authorization tracking: where delivered care turns into a denied claim.
Trace most denials back far enough and you find the same root cause, an authorization that lapsed, was never updated, or was never attached to the billed visit.
Why gaps happen even in well-run agencies
Authorizations expire on a calendar but care does not pause. A member on a stable schedule keeps receiving visits after the auth quietly runs out, and the denials arrive weeks later.
A change in service level, from personal care to skilled or from hourly to live-in, needs a new authorization, and the request often gets overlooked in the handoff between clinical and scheduling.
The authorization on file does not always match what billing actually submits. Codes, modifiers, or unit counts drift, and the payer sees a claim that does not correspond to what it approved.
Across multiple branches or coordinators, accountability gets diffuse. Everyone assumes someone else is watching the expiration date.
What the renewal calendar should look like
Work a 45-day horizon before each expiration. Use the first 15 days to gather clinical documentation and the updated plan of care, 15 days for payer processing, and 15 days for follow-up on anything that comes back incomplete.
Set a hard escalation at 30 days out. Anything not moving by that point goes to a supervisor, not another reminder. Review the full expiring-window list weekly, not monthly.
When to pursue retroactive authorization
Medicaid fee-for-service programs often have a formal retroactive authorization process, and it usually requires clinical-necessity documentation showing the care was appropriate for the period in question.
Managed-care plans vary widely. Some allow retroactive requests with a defined window and required documentation. Others treat any post-service request as an appeal.
The overall filing window constrains how long the option stays open. A retroactive auth granted after the timely-filing deadline still cannot be billed.
Build it into the daily workflow, not the monthly audit
A monthly review finds the lapse after the denial. By then the visits are already delivered against a dead authorization and the recovery path is narrow.
A weekly report of authorizations by status, expiration date, remaining units, and covered codes finds the gap before care is delivered against nothing. That report is the difference between preventing the leak and cleaning up after it.
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.
Find the auth gaps before the denial arrives.
The Margin Review reads authorizations against delivered and billed visits for one closed period and flags every visit that will not reconcile at the payer.