Atlantic Home Health Revenue Partners

The Situation

Atlantic Home Health Revenue Partners was one of the larger independent billing operations Mirlo Systems has worked with: 78 staff, 14 home health agency clients, and $7.8M in annual collections. At that scale, a systematic billing failure does not show up as a line item. It shows up as compressed margin, unexplained AR growth, and a staff team that is always behind no matter how many hours they work.

The owner had been in the home health billing space for 14 years. He ran a tight operation by most measures. His staff were experienced. His denial rate was 9.2%, which he considered acceptable for home health given the Medicare documentation burden. What the audit revealed was that 9.2% concealed two specific failure modes that were costing the business $640,000 per year, and both were entirely preventable.

Home health billing at $7.8M means managing OASIS documentation cycles, RAP submission windows, and Medicare PDGM episode billing across a high volume of active patients. At that scale, eligibility errors that slip through at intake compound across thousands of episodes per year. A 2% eligibility error rate on 7,800 annual episodes produces 156 eligibility-based denials. At an average episode value of $2,400, that is $374,000 in challenged revenue annually from intake errors alone.

What Was Breaking

The eligibility verification process at Atlantic was running a single check at intake. Home health episodes run 30 to 60 days. Coverage changes, plan transitions, and Medicaid redetermination events that occurred after the initial eligibility check were not being caught before billing. Claims were going out on coverage that had lapsed or changed. CO-270 and eligibility-sequence denials were appearing consistently across the AR but had never been aggregated to reveal the total volume and dollar impact.

The second failure was timely filing management across 14 clients with different payer mixes and different episode billing cycles. Medicare RAP submission deadlines and final claim submission windows were being managed manually in a shared spreadsheet. The spreadsheet had not been updated to reflect two clients whose payer mix had shifted significantly in the prior year. Claims for those clients were missing submission windows at a rate that produced $266,000 in timely filing write-offs over 18 months.

A third issue was OASIS documentation lag. Seven of the 14 clients were submitting OASIS assessments with an average charge lag of 9 days from the episode start date. In PDGM billing, late OASIS submission delays the entire episode billing cycle. Across the volume those seven clients represented, the cash flow impact of a 9-day charge lag was material: approximately $180,000 in revenue delayed per month relative to what a 3-day lag operation would achieve.

The Build

Mirlo Systems built a mid-episode eligibility re-verification system for all active home health patients at the 14-day and 30-day marks within each episode. Coverage changes and Medicaid redetermination events were now caught while the episode was still active, before billing. Eligibility-based denials dropped from 156 per month to under 11 per month. The $374,000 annual denial exposure from eligibility failures reduced by over 90% within two billing cycles.

The timely filing spreadsheet was replaced with a payer deadline registry that tracked RAP and final claim submission windows for every active payer across all 14 client accounts, updated automatically when payer mix changed. Claims approaching 50% of their filing window without confirmed submission triggered an alert. No claims have been lost to timely filing since the system went live.

OASIS charge lag was addressed by building an episode start date alert for each of the seven high-lag clients. When an OASIS assessment was not received within 3 days of episode start, an automatic escalation went to the relevant clinical contact at the agency. Average charge lag across those seven clients dropped from 9 days to 2.8 days within 60 days. Monthly revenue cycle timing improved materially as a result.

Each of the 14 clients received a monthly billing performance report showing episode billing cycle time, denial rate, clean claim rate, and AR aging by payer. Two clients who had been on the verge of requesting competitive bids for their billing contract renewed for three-year terms within 60 days of receiving their first performance report. The reporting function became a retention and growth asset.