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Question on private insurance home health care payments

jaxmedco jaxmedco (New) New

Hi all,

Quick question I am hoping someone can answer. In general, do the insurance companies of privately insured patients require that you have contracted rates for home health care services or is it just a matter of the patient is responsible for charges above and beyond the policy limits?


Your question is difficult to understand, but in a case where I once worked, the insurance company paid for the amount of care that they authorized and left the patient's mother on the hook for anything above and beyond. Since her coverage had been cut over the years because agencies could not meet her needs, that was a lot. Her elderly parents provided a lot of care and she paid nurses out of her own pocket. At one point, her insurance company decided to cut the home health agencies out of the picture. They paid the nurses directly but strangely enough, did not raise the hourly rate of pay for those nurses.

Those payment arrangements are variable because they are administered by different types of insurance providers. Some of those home care cases are paid by workers comp, some by auto, some by personal liability, medicaid, etc. So the policies/benefits differ somewhat.

Most commonly I have worked with companies that pay for a certain "amount" of skilled and unskilled care as described above by caliotter3 leaving out the part about paying nurses individually as a practice.

Generally speaking, the insurance provider requires a medical opinion/order for the level of care/support that the patient requires and will then administer the terms of the benefit/policy. Just like with anything else, the insurer generally pays only a portion of the cost and the beneficiary of the claim is responsible for a percentage.

Does that help?

Sure does, thanks to both of you.

KelRN215, BSN, RN

Specializes in Pedi.

If the agency is an "in-network" provider with the insurance company, they have a contract with that insurance company that determines what the reimbursement rate is. It may be (and likely is) less than what the agency bills out at. By entering into this contract and becoming an in-network provider, the agency waives their ability to charge the patient the balance. My agency bills out at $120/visit. We have some insurances that reimburse us about half of that and there is no out of pocket cost to the patient because we are "in-network" with their insurance company. If an agency agrees to service a patient with an out-of-network policy, the patient may have some out-of-pocket costs. If a patient's plan has limits- like 60 visits max per calendar year or something- the patient has no benefits beyond those 60 visits and would be responsible for the cost of any visits beyond that, unless they have secondary insurance. Also, if the plan has a deductible, that usually needs to be met before the insurance starts paying for home nursing services.


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