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Looking at Cash


I am by education and preference a nurse. I serve as a clinical consultant to my clients. I have no education or experience in business and I have absolutely no aptitude for accounting. So, why do I look at cash?

Actually, there are only limited numbers I look at when it comes to cash. The first and most important number to me is the length of time it takes for an agency to bill a RAP. Although from a billing perspective, RAPs are simple, there are numerous clinical and patient care functions that must be complete before dropping a RAP.

  • The patient must be admitted/recertified
  • All paperwork is submitted to the office
  • A plan of care is built
  • The physician has been contacted
  • Data entry has done their job
  • Billing has all the relevant information to drop a RAP

If RAPs are delayed beyond seven days, chances are one or more of these processes are being delayed. This might mean that admissions are not turned into the office in a timely fashion or that data entry is behind in their work load. Whatever the cause, it probably means that the patient is being seen by visiting staff who do not have access to a plan of care. Considering that 25 percent of all hospitalizations occur within the first week of home health care, these processes could dramatically affect the patient’s level of care.

In a perfect world, five days is reasonable for a RAP to be dropped. It is a very lofty goal and is usually only attainable in a very stable, well staffed agency with electronic documentation that eliminates much of the data entry. In smaller paper based agencies where staffing is limited, I am content with 7 days. But, the number of days it should take is not determined by me! It is determined by your agency.

End of Episode claims are expected to take a little longer to get out of the door. Physician signatures are required and there is only so much that an agency can control when it comes to physician signatures. Additionally, a thorough billing audit should be performed to ensure that each claim meets the standards of the payor source.

However, if the end of episode billing audits are uncovering a vast number of orders that need to be written to correct frequencies, medications, etc., then they will be delayed even further. Even the most cooperative physician in the world will not sign orders that haven’t been written.

Two weeks is generally acceptable for End of Episode claims. Anything beyond that suggests that visit notes aren’t on charts and orders haven’t been written contemporaneously with the services provided.

When it comes to RAPs and EOEs I also get concerned when the numbers are too low. Could that mean that important clinical and regulatory steps are being overlooked?

The amount of money tied up in RTP and ADR status can also tell me a lot about the overall efficiency of the agency. RAPs should never be reclaimed because EOE claims haven’t been billed timely but I see that more frequently than I should. An excessive number of RTPs could mean sloppy billing processes.

So, if you are a nurse in a management position and you don’t know these numbers, you may be operating from a compromised position. If your billing department cannot tell you these numbers off the top of their heads with reasonable accuracy, they are not working within a system that provides benchmarks for performance. If no one can tell you these numbers, I can almost assure you that your agency has problems.

If you have any questions or comments, I always welcome them in the comment box below or you can email me directly at

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