ScenarioPlusby Waiver Academy
‹ Bill It Right

Pocket guide · Billing

Bill It Right

Bill what you did. Nothing more.

  1. Bill only what's authorizedOnly bill services that are in the person's approved plan, within the authorized amount. If someone needs a service that isn't authorized, tell the case manager so the plan can be updated first. Work outside the plan can't simply be billed. Episode 1: Not in the Plan
  2. Bill the real timeBilling units must match the time actually worked, counted using your program's written rounding rules. Rounding up out of habit, even by a few minutes, adds up to money the agency wasn't owed. When in doubt, check the program manual. Episode 2: Units Don't Lie
  3. No note, no billEvery billed visit needs documentation that shows the care given, written by the person who gave it. If the note is missing, hold the claim and ask that staff member for a late entry. Billing staff never write care notes, and a visit without a note isn't billed. Episode 3: No Note, No Bill
  4. Pause billing during a hospital stayWhen someone is admitted to a hospital, their home care visits usually stop, and so does billing for them. Pause the schedule as soon as you hear, tell the case manager, and correct any claims already sent for those days. Episode 4: While She Was in the Hospital
  5. Bill the service you gaveBill the service code that matches the care actually provided and authorized. Billing a higher-paying code because it's close is upcoding, and it's fraud. If someone needs a different service, ask for it to be added to their plan. Episode 5: The Higher Code
  6. Catch overlapping timesA staff member can't be billed in two places at the same time. When visit times overlap, hold both claims, check the visit records, and talk to the staff member. Bill only what really happened, and check for overlaps every week. Episode 6: Two Places at Once
  7. One visit, one claimEach visit is billed once. If a claim seems stuck, check its status before doing anything, and never simply send it again. If a duplicate goes out, cancel or void it the proper way, and return any double payment. Episode 7: Billed Twice
  8. Fix the cause, not the recordWhen a claim is denied, read the reason, fix the real problem, and resubmit correctly if it's allowed. Never change dates, codes or records to make a claim go through. Track authorization end dates so the same denial doesn't happen again. Episode 8: Denied
  9. Report and return overpaymentsWhen you find you were paid more than you should have been, report it and pay it back within the time your program's rules set, even if nobody else has noticed. Write down what you found, how you fixed it, and what changed so it doesn't happen again. Episode 9: The Overpayment
  10. Check yourself firstDon't wait for an audit. Each month, check a sample of claims: the plan authorizes the service, the visit times are real, the note supports the care, and the claim matches. Fix and record what you find, and make it safe for staff to raise billing worries. Episode 10: Audit Ready