Home care revenue recovery: how agencies get back what they are owed.
Most agencies are not collecting everything they earned. The gap lives in unworked denials, delivered-but-unbilled visits, and claims paid at the wrong rate.
What revenue recovery means
Two things at once. Historical losses still inside their filing and appeal windows, and ongoing leakage that will become historical loss next quarter if the process does not change.
Filing windows run 90 days to 12 months depending on the payer and state. Appeal windows run on their own separate clock, commonly 30 to 120 days from the date on the remittance or denial notice, and they vary by payer and state. Both are hard: past the window, the money is gone regardless of whether the claim was correct.
The five categories, by frequency
Denied claims never worked. The most common single category. Look for CO-50 medical necessity, CO-4 modifier inconsistent with procedure, CO-29 timely filing on claims that in fact went out on time and had a payer error.
Authorized-but-unbilled visits. Found on a 90-day look-back by reconciling scheduling against submitted claims. Care was delivered and documented but the claim was never built.
Lapsed-authorization denials. Retro-authorization policy varies widely by state and MCO, and many are recoverable if the request goes in within a defined window with the right supporting record.
Rate and modifier mismatches. Silent underpayments caught by comparing the remittance line to the contracted rate for that code and modifier combination. The claim adjudicates and pays, just at less than it should have.
EVV documentation gaps. Visits pay at first pass, then recoup on audit, and the window to supply the missing record is usually short.
How to run a 90-day recovery review
Work the denial queue oldest-first, checking filing and appeal deadlines before writing anything off. Reconcile authorizations to billing for the period, isolating auths that expired mid-period with visits after the expiration. Sample 30 to 50 remittance lines against the contracted rate for each major payer. Pull the EVV exception logs for the period and reconcile against submitted claims.
What timely filing means in practice
Hard deadlines. Medicaid fee-for-service commonly 90 days to 12 months, some as short as 60. Managed care shorter than the underlying Medicaid clock. Medicare 12 months. Appeal windows run on a separate clock entirely, commonly 30 to 120 days from the date on the remittance or denial notice. Confirm your own before you write anything off.
Build it so it does not recur
Auth-expiration monitoring so lapses are caught before the next visit. Scheduling-to-billing reconciliation on a weekly cadence. A denial work rate as an operational metric. Contracted-rate verification on a rotating sample.
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.
Get back what you are actually owed.
The Margin Review runs on a closed period and returns a ranked list of recoverable dollars by reason, capped at the authorized ceiling.