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At a National Alliance for Care at Home meeting, industry speakers said home health agencies face lower average revenue per visit and more administrative work for Medicare Advantage patients than for traditional Medicare patients. Homecare Homebase data put the gap at $60 per visit and about 13% more weekly office workflow; the figures are company data, not a government-wide measure. Speakers said the growing share of Medicare Advantage patients is prompting providers to review operations and negotiate payment terms.
Home health agencies receive an average of $206 per Medicare Advantage visit, compared with $266 under traditional Medicare, while weekly office workflow for Medicare Advantage patients is about 13% higher, according to Homecare Homebase data presented at the National Alliance for Care at Home’s Annual Meeting & Expo. The figures point to a growing operational and revenue challenge for providers as Medicare Advantage makes up a larger share of their patients.
Hannah Pearson, chief revenue officer of Homecare Homebase, said the company’s data show weekly visits per patient and rehospitalization rates are approximately the same across the two patient populations. The comparison therefore describes similar levels of clinical activity alongside lower average revenue and more office work for Medicare Advantage cases, according to Pearson. The data are from Homecare Homebase, which supplies technology and administrative services to home-based care providers.
Medicare Advantage accounted for 49.5% of patients in the company’s dataset, up 31% since 2016. Pearson said many agencies built staffing, workflows and contracts when traditional Medicare represented a much larger share of their business. The changing payer mix, she said, calls for providers to reconsider how they organize operations.
Nick Seabrook, executive vice president of SimiTree, said a CMS cost-report category that includes Medicare Advantage and other payers has consistently operated at a loss. Because that category combines multiple payer types, it does not isolate Medicare Advantage results. Seabrook also said total registered nurse visit costs approached $230, about $60 above their level when the Patient-Driven Groupings Model began. He cited CMS data showing overall margins near 7% when the model was first implemented and about 3% over the last three years, through 2024.
The Strain of a Shifting Payer Mix
The reported gap matters because Medicare Advantage is no longer a small part of the patient mix in the Homecare Homebase dataset. At nearly half of those patients, its payment and administrative requirements can affect agency staffing, billing capacity and financial planning. Agencies built around traditional Medicare assumptions may have to revise processes as more of their work involves Medicare Advantage plans.
The figures do not establish that every agency or plan has the same payment gap, paperwork burden or margin. They are company data presented by an industry executive, and the cost-report findings cited separately include payers beyond Medicare Advantage. Still, the speakers’ comparison highlights the practical problem providers say they face: similar clinical activity may be paired with different reimbursement and administrative demands.
Seabrook said agencies may be able to pursue episodic contracts with Medicare Advantage plans that more closely resemble traditional Medicare payment, instead of accepting per-visit terms. He said plans have become more receptive to such arrangements. Negotiations may give providers another route to address the gap, though the discussion did not establish how many plans would agree or what rates they might offer.
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The Patient-Driven Groupings Model, or PDGM, is a Medicare payment model for home health care. Seabrook used its implementation as a reference point for cost and margin trends, saying overall margins were around 7% at the outset and had hovered around 3% in the three years leading up to the cited CMS data through 2024. These figures refer to overall margins, not a Medicare Advantage-only measure.
Traditional fee-for-service Medicare and Medicare Advantage are distinct payment arrangements. Medicare Advantage plans are offered by private insurers under the Medicare program, and providers may encounter different contract and administrative requirements across plans. Homecare Homebase’s reported patient-share figure rose to 49.5% in its dataset, a 31% increase since 2016. The source does not specify a separate industry-wide estimate, so that share should not be treated as representative of all home health agencies.
““Medicare is really our only payer source in home health that’s making any kind of a positive margin.””
— Nick Seabrook, executive vice president of SimiTree
Limits of the Available Figures
The $266 and $206 average revenue figures and the 13% workflow comparison come from Homecare Homebase data. The report does not provide the dataset’s sample size, the exact period covered, or a breakdown by plan, region or agency. It also does not define precisely how weekly office workflow was measured. The figures should not be read as a universal rate or as a government-wide comparison.
The margin evidence has a separate limitation: the cost-report category Seabrook referenced includes Medicare Advantage and other payers, so it cannot show Medicare Advantage’s standalone financial performance. The reported RN visit cost is also a total cost figure, not a payment rate. The source does not specify which plans have accepted episodic contracts, how common those agreements are, or whether negotiated rates offset administrative expenses.
Contract Talks and Clinical Evidence
Seabrook advised agencies to contact their Medicare Advantage plans and ask whether they would consider episodic, Medicare-like reimbursement rather than per-visit payment. He said providers should be prepared to support negotiations with clinical outcome information. The meeting discussion did not announce a new policy, payment rule or agreement between agencies and plans.
Further detail from agencies, insurers and broader datasets would help show whether the reported revenue and workflow differences apply across the sector. For now, the next steps described by the speakers are operational review and payer negotiations; it remains unknown how plans will respond or how any contract changes would affect agencies’ finances.
Key Questions
What is the reported payment difference per visit?
Homecare Homebase data put average revenue at $206 per Medicare Advantage visit and $266 per traditional Medicare visit, a $60 difference. The figures were presented by the company’s chief revenue officer and are not identified as a universal industry rate.
What does the 13% paperwork figure measure?
Pearson said weekly office workflow for Medicare Advantage patients is approximately 13% higher than for traditional Medicare patients in Homecare Homebase data. The source does not give a detailed definition or measurement method for that workflow comparison.
Are Medicare Advantage patients receiving more visits?
Pearson said weekly visits per patient and rehospitalization rates are approximately the same across the two populations in the company’s data. The report does not provide detailed patient-level figures.
What are agencies being advised to do?
Seabrook recommended that agencies ask Medicare Advantage plans about episodic contracts with reimbursement closer to traditional Medicare rather than per-visit payment. He said providers should bring clinical outcome information to those discussions.
Source: homehealthcarenews.com
