The care was delivered. The money did not follow.

The software we had could tell us pieces of what was happening. None of it could tell us what was happening to the business.

An agency does not fail for lack of work. Ours had referrals, nurses in the field and patients who were well cared for. What it did not have was a dependable way to turn a completed visit into a finished note, a finished note into a bill, a bill into a payment, and a payment into the cash that makes payroll on Friday.

I did not see it in those terms at the time. I saw a list of separate headaches, one per line of business, and I tried to solve each one separately. The agency ultimately closed. It took me years to understand that the headaches were the same problem.

Four businesses, one piece of software

Our main system was a well-known home health product designed around Medicare. For the Medicare patients it was working in the world it was built for: episodes, assessments, certifications, claims. It cost us about two thousand dollars a month, and for that one line it was a reasonable tool, although even there we never achieved a reliable clearinghouse connection for that workflow.

Everything else we did had to be pushed through that system or kept outside it.

The VA: years to learn how to be paid

The VA sent us patients, and we cared for them. Billing for that care was another matter. Our software could not produce a VA claim we could trust, so we filled in institutional claim forms manually with a program that came on a CD-ROM and printed the form as a PDF.

Producing the form felt like the solution. It was not. A form that prints correctly still has to be submitted the way the payer requires, accepted, corrected when it is rejected and matched to a payment. Long after the agency had closed, a biller was still going into the VA’s payment system to correct those claims by hand so that work done years earlier could finally be paid.

That experience is the reason I do not think of a claim form as billing. The form is the last few inches of a long process. We had the form. We did not have the process.

Infusion: where a late note became a late paycheck

Home infusion nursing runs on documentation. The pharmacy sends the order and the drug. The nurse goes to the home, starts the infusion, monitors the patient and writes the note. The pharmacy needs that note back, and the agency is paid by the pharmacy for the visit.

Our notes were late. Part of that was nurses, who are busy and who were documenting in screens designed for a Medicare visit. Part of it was delivery: once a note existed, getting it to the right pharmacy in the form that pharmacy wanted was its own manual step. So notes reached pharmacies late, invoices went out late, and pharmacies paid late. The same gap, seen from the pharmacy’s side, is described in keep your pharmacy system, connect the nursing operation.

The nurses, quite reasonably, expected to be paid on time. I was regularly trying to make a payroll for work whose revenue was still weeks away, and I could not have told you on any given day how much money was sitting in notes that had not been turned in.

Private pay: a business that needed its own everything

Private-pay clients are a different business again. There is no payer authorizing care. There is a family, a contract that says what will be provided and at what rate, a deposit, a caregiver who has to be recruited and matched to that particular client, a schedule measured in shifts instead of visits, and a supervisor who has to check on the care.

None of that fit in a Medicare system, so it lived in another one. The contracts, the deposits and the hiring for those clients were now invisible to the system that held everyone else.

One of our private-pay cases was a 24-hour live-in client in East Texas. We staffed the case with licensed vocational nurses working shifts around the clock. On paper it was a good piece of business. But round-the-clock private-pay care is a different operating model: coverage for every shift, handoffs between nurses, supervision, communication with the client and the family, the contract, the deposit, payroll and day-to-day management. We did not have a system built to hold all of that together. The clinical work could be staffed. The management structure around it was fragile, and eventually the case fell apart.

That experience taught me that a profitable-looking case can become operationally unmanageable when the software does not match the business model. Private pay is not Medicare home health without Medicare. It has its own chain, from the client agreement and payment terms through hiring, coverage, supervision, shift documentation, payroll and invoicing to the family on the other end.

What the fragmentation cost

Each line had a headache we could not cure, because the cure for each one was in a place the other systems could not see.

The lesson I took from it

It would be easy to tell this as a story about bad software. That is not what I learned. Each product we used did the job it was designed for. The trouble was that each was designed for a piece of an agency, and our agency was not a piece. The organization itself had to bridge the gaps, and an organization that is busy caring for patients bridges them badly.

Care could be delivered successfully while the agency still struggled to turn that work into documentation, documentation into billing, billing into collections, and collections into the cash it needed to keep operating. Every one of those conversions was a place where work could stall without anyone seeing it.

One system does not mean one workflow

The obvious answer is to put everything in one system, and that is half right. The half that is wrong is the half we had already lived through: taking software shaped for one line of business and forcing the others into it. Infusion in a Medicare system is still fragmentation. It is just hidden inside one login.

The principle we are building Paloma on is this: one operating system, with different clinical, payer and billing rules for each line of business. Medicare home health should work the way Medicare requires. VA care should carry its authorization and bill the way the VA accepts. Home infusion should know the pharmacy’s contract, its documentation requirements and its rates. Private pay should know the agreement, the deposit and the family.

Underneath, they share what is truly common: a patient, a clinician, an order, an authority to provide the service, a visit, the evidence of it, an obligation satisfied, something billable, a claim or invoice, a payment and the cost of the clinician who did the work.

A claim form is an output

The VA taught me to separate the questions a billing process has to answer from the paper it eventually produces. Paloma’s revenue cycle is designed around the questions.

The picture an owner needs

What I wanted, and never had, was one screen that told me where the money was. Not revenue as a single figure, but the work of the month laid out by how far it had travelled toward cash, across every line of business at once.

With that picture an owner can see that a known amount of this month’s work is waiting on notes, another amount is waiting on review, another is billed and unpaid, and another was rejected and needs a correction. Set beside what is owed to clinicians this week, it becomes the thing I lacked most: an honest view of whether the agency can make payroll, and what to do today if it cannot.

That view is only possible when the visit, the note, the review, the bill and the payment are the same record seen at different moments. It cannot be assembled reliably from three systems, a stack of paper claims and a payer’s website.

Why this is how Paloma is being built

Paloma began with home infusion nursing because it is a line of business where the whole chain can be made to work from end to end: referral, order, authorization, staffing, visit, note, review, delivery to the pharmacy, invoice, payment and reconciliation. It is also the line where I felt the cost of a late note most directly.

It is not where Paloma is meant to stop. We are building toward the agency I actually ran: one company operating several lines of care, each with its own rules, with one operational and financial truth for the people responsible for it. Medicare home health, VA care and private pay are part of that direction because they are part of the reason the architecture exists. Each is added to the same backbone in sequence, so that an agency entering a new line does not have to buy and connect another system to do it.

A True North that described only what has already shipped would be a release note. This is the destination, and the experience that set it.

The Paloma True North →   Revenue cycle →   Payer and program models →   Service lines →

Published by Paloma Health Technologies. Written from the experience of a registered nurse and healthcare agency operator.