Intake & Eligibility Verification

Why intake decides the margin

Medicare home health pays under the Patient-Driven Groupings Model: 30-day payment periods, with reimbursement determined by admission source (community or institutional), timing (early or late), clinical grouping, functional impairment level and comorbidity adjustment. Revenue is case-rate based, not visit-based.

You do not get paid more for doing more visits. You get paid for accurate documentation, correct coding, and proper clinical positioning. Margins are won or lost at intake, coding, and documentation. Home Care 101 — Paradygm Health Group

Read that last sentence as an org chart. Intake is not the front of the funnel; it is the first of the three places your margin is actually set.

What intake actually does

• Confirms eligibility before cost is incurred. Not after the first visit, not at billing.
• Identifies payer type — Traditional Medicare or Medicare Advantage. The two behave nothing alike downstream.
• Determines prior-authorization requirements — and hands them to the people who obtain them.
• Prevents unbillable admissions — the patients who cost you money from day one.

Where it leaks

Home Care 101 lists poor intake qualification — admitting low-reimbursement patients — first among the financial leaks that sink agency margin, ahead of incorrect OASIS scoring, missed comorbidity capture, delayed physician signatures, weak prior authorization, billing lag, high LUPA rates, and denials and ADR exposure. Every one of those is an operational failure, not a clinical one.

Most agencies do not fail clinically. They fail operationally. Home Care 101 — Paradygm Health Group

Why we staff it with a nurse

You can hire a remote nurse to do your intake at a fraction of the cost of a typical front-desk employee. That's the offer, and the reason it's a nurse is the work itself: qualification is a clinical judgement. Documentation has to support homebound status, medical necessity, skilled need and plan-of-care adherence — and the person deciding whether a referral clears that bar should be able to read a chart.

Clean intake and qualification is the first of the five pillars of a high-performing agency, alongside accurate clinical documentation, fast physician coordination, tight revenue cycle management and strong QA oversight. We staff four of the five.

The metrics it moves

Case-mix accuracy, denial rates, Days Sales Outstanding, LUPA percentage, episode profitability, audit exposure. Home health is a margin discipline business, and small percentage improvements in reimbursement accuracy, claim turnaround and denial reduction compound into meaningful annual margin.

Where it goes next

Intake hands off to prior authorization (it determined the requirement), to QA and OASIS review (it set the clinical positioning), and to documentation management (it started the clock on the plan of care). Staffed separately, they behave like one chain — which is the point.