Ep 63: Home Health OT vs OT in the Home: Differences in Billing and Practice

Transcript of the Amplify OT Podcast Episode 63: Home Health OT vs. OT in the Home

Host: Clarice Grote, MS, OTR/L

Podcast published on May 20, 2025

Episode Introduction

Providing OT in the home or doing mobile outpatient has become so much more popular in the last few years, especially for individuals who are branching out into their own private practices. But if you’re working for one of these companies or you’re considering starting your own, it’s really important to understand the difference between home health when we talk about home health agencies versus what we tend to refer to as OT in the home.

Amplify OT Podcast Intro

Hey OT Amplifiers, and welcome to the Amplify OT Podcast. I’m Clarice Grote, an occupational therapist, the founder of Amplify OT and a self proclaimed policy nerd who actually enjoys reading the long documents that most people avoid. No matter where you are in your occupational therapy journey, you belong here as an important part of this community. The work you do matters, your voice matters, and advocacy isn’t just possible, it’s powerful. So let’s get started because change starts here.

Home Health OT vs OT in the Home

Hey OT Amplifiers. And welcome back for another episode of the Amplify OT Podcast. I am so sorry that it’s been so inconsistent for 2025, but I promise we’re getting back on track and we’re starting off strong with an episode about what exactly is the difference between home health occupational therapy and OT in the home or our mobile Part B providers?

Understanding the differences between these two settings is really crucial for navigating billing documentation, understanding what types of care that patients are eligible to receive, and if you’re thinking about starting your own business, understanding what language to use when you’re asking questions. Because sometimes, if you use the wrong language, you will get the wrong answer. So, let’s get started.

The Basic Differences between Home Health OT and OT in the Home

The TL;DR of the difference is that when we talk about home health occupational therapy, we tend to be referring to home health services that are provided by a home health agency and covered under Medicare Part A. A home health agency is a completely different type of company that’s required to have different types of employees.

Versus when we talk about mobile outpatient or OT in the home, we tend to refer to a service that is covered under Medicare Part B and it’s basically billed as if you went to an outpatient clinic, except the patient is receiving the services in the home and these services are typically not provided by a home health agency. Now, your home health agency may at times also bill Medicare Part B that is becoming more popular as an additional revenue stream, but it’s not super common.

There aren’t very many large companies that we think about when it comes to OT in the home or mobile Part B services. The main one that most people know is Fox Rehab. They are not a home health agency. They, just provide OT outpatient services in a patient’s home. So they’re not a home health agency. They are more of a mobile outpatient clinic.

And if you find folks that are working in home mods or home accessibility, those sorts of assessments, those also tend to be mobile part B or mobile outpatient services, not home health. So let’s focus in a little bit more on home health or what we may call traditional home health, where or services provided by a home health agency.

Join the Amplify OT Learning Platform today to gain immediate access to on-demand lessons and webinars to help you see the opportunities for OT in healthcare. Join us at amplifyot.com/membership today!

How is Home Health Covered Under Medicare?

So home health occupational therapy services are covered under Medicare Part A. This coverage is provided by a certified home health agency and it’s delivered to patients who are homebound due to an illness or injury or they need intermittent therapy services. In this context, home health is considered part of that post acute care continuum, which includes ltch, snf, inpatient rehab and home health.

Homebound Status

In order for these services to be covered under Medicare Part A under the home health benefit, there has to be some specific criteria that’s met. And this is where we have that admission criteria, where a patient has to have what’s called a homebound status. Now, contrary to popular belief, it does not mean that the patient cannot leave the home or that the patient can’t drive.

What homebound actually means is that it has to be very difficult for the patient to leave the home without special assistance or it’s medically contraindicated for that patient to leave the home.

If a patient drives, are they considered homebound?

However, if your patient is getting out of the house, driving to work, driving all over the place every single day, they probably are not necessarily considered homebound. But if they’re only driving maybe once or twice a week to go to the grocery store or to go to church, they may still be eligible for that homebound status.

Intermittent Skilled Therapy

The second criteria that a patient has to meet in order for home health to be covered under Part A is, is that they need intermittent skilled services. Don’t let the term intermittent hang you up. This is basically just differentiating between what kind of services a patient would receive in a SNF or an inpatient rehab facility, which would be daily skilled care versus in home health, it is not daily skilled care, it’s intermittent skilled care.

So someone has to be able to remain healthy enough to not receive a visit every single day.

Need for a Qualifying Service

Now, under the Medicare Part A benefit, there needs to be what is called a qualifying service. And these qualifying services are nursing, physical therapy and speech therapy. You will notice that occupational therapy is not included on that list.

Now, I do have additional articles and, I believe, also a previous podcast diving into a little bit more of what it means to be a qualifying service. But to quickly summarize it here, essentially what it means to be a qualifying service is that at least one of those services has to be on the initial order in order for Medicare to cover that home health episode of care.

If only occupational therapy was on the order, or if only OT services were provided, then Medicare would deny the claim because OT is not a qualifying service.

Advocating for OT to be a Home Health Qualifying Service

And before you start bringing out the torches and the pitchforks, know that advocacy is happening. This has been an issue since the 80s when the prospective payment system was initially developed by Medicare due to a misunderstanding of what occupational therapy actually is and home health looked very different at the time.

We have made significant progress in advocating for OT to be a qualifying service. First we had the passage of the Home Health Flexibility act which allowed OTs to complete the initial start of Care Oasis. And now we have reintroduced the Home Health Accessibility act which if passed would add occupational therapy as a qualifying service.

Call to Action: Support the Home Health Accessibility Act

And to support this piece of legislation being passed by Congress, I would encourage you to go to aota.org/takeaction, which we’ll link in the Show Notes, which is their Take Action page or Legislative Action center where you can spend like 5 minutes to contact your legislator and ask them to pass the Home Health Accessibility Bill.

And just as a quick advocacy side note, if you work in this setting or you know someone who has not been able to receive home health because OT is not a qualifying service, then I need you to share that story with your legislators. It’s those kinds of personal stories that can really move the needle when it comes to advocating for the Home Health Accessibility Act.

Home Health is Covered Under Medicare Part A

Okay, the other big difference about home health services is that they are covered under Medicare Part A, or they’re also typically covered under other insurances like Medicare Advantage or commercial insurance.

But for Medicare Part A it is reimbursed under the payment model called PDGM or the Patient Driven Groupings Model. Again, we have a full article and podcast episode on PDGM. We also have a really intensive lesson on home health and PDGM in the Amplify OT Learning platform. But to kind of sum it up, it’s essentially functions like a bundled payment model where the payment is based on function, comorbidities, diagnosis and those sorts of things.

And home health agencies are paid in a lump sum for 30 day episodes of care. So this is a value based program. So again it’s reimbursed under Medicare Part A PDGM and it has to be provided by a home health agency.

Making Sure You Use the Correct Terminology

So if you work in a mobile outpatient clinic or you want to start your own kind of mobile outpatient clinic, it would not be accurate to advertise those services as home health OT, because it is not provided by a home health agency and could be confusing to beneficiaries, to providers, as to what kind of service you’re actually offering and how that service would be covered.

This is also important as you work through getting business licenses, those sorts of things. You do not want to get a license for starting a home health agency. If you are starting a home health agency, which is fantastic, you do have to provide services such as nursing, the therapy services, home health aides, and those sorts of things which a mobile outpatient clinic would not need to do. So they are very different in terms of how they are licensed and registered by the states, but also how they are reimbursed under insurance.

What Occupational Therapy Looks Like in Home Health

And one of the other differentiating factors is what occupational therapy actually looks like in home health versus mobile outpatient. So unfortunately, in home health provided by a home health agency, occupational therapy tends to be relatively limited.

And this has been largely blamed on payment cuts over the last few years for pdgm, on the changes in bundled reimbursement. And so there are many home health agencies who try and restrict occupational therapy to three or fewer visits.

 Now, I think it’s always important to note that per the Medicare Part A benefit, there is no limit on medically necessary therapy services, and the policy is very clear about that. However, in practice, agencies do try and put a lot of pressure on therapy providers to reduce the number of visits that they are providing in order to stay within that payment of PDGM.

So if you worked in home health prior to 2020, or your patient received home health prior to 2020, what occupational therapy looks like under a home health agency is very different than it was, and likely it’ll be far fewer visits because reimbursement is no longer driven by the number of therapy visits. So we have to be creative in other ways that we advocate for occupational therapy.

Specialty OT Services in Home Health

Additionally, another main difference of what OT looks like in home health is that we are not typically doing home modifications or home assessments in home health. However, we do still make recommendations for home mods or for accessibility, equipment, DME, those sorts of things.

 But that’s different from when we talk about some of these other clinicians that are doing these very intensive home modifications and assessments, potentially working with a builder and a contractor, those sorts of things. That is different from what it kind of looks like in Home health, which makes sense when you think about the fact that we may only see the patient a couple of times.

I will also say that generally speaking, OT practitioners working in home health agencies tend to be more generalists versus specialized. That is not always the case. There are absolutely clinicians with specialty training like lymphedema, low vision, those sorts of things working for home health agencies. It’s just that we tend to see a more specialized service be more common for mobile outpatient clinics because you have more control over over the type of individual that you are seeing.

Presence of Occupational Therapy Assistants in Home Health

And the last thing that I’ll mention before we start talking about OT in the home is that there is also a larger presence of occupational therapy assistants in home health than there is in mobile outpatient clinics. And we’ll talk about why that is when we dive more into mobile OT and why that is hopefully changing. But, historically, there has been a much larger presence of OTAs in home health working for a home health agency than in mobile outpatient clinics.

So that is kind of the main summary of what home health is. And then after this quick break, we are going to talk about mobile outpatient or OT in the home.

Ad Break: Thanks for Supporting Amplify OT!

This is an affiliate link for Medbridge. Using our code gives you the best price and supports the content you love on Amplify OT!

OT in the Home or Mobile Part B Outpatient Services

And we are back. So let’s dive into what is OT in the home, or what we call Mobile Part B, Mobile outpatient, home mods. It goes by a lot of different names, but generally, these are practitioners who are either working for themselves or working for some sort of outpatient clinic. But they are providing outpatient services in a patient’s home or living environment.

How is OT in the Home covered by insurance?

When it comes to reimbursement and admission criteria and eligibility, it is very different from what is provided by a home health agency. First and foremost, if the patient’s a Medicare patient, it is billed under Medicare Part B, it is not billed under Medicare Part A. OT in the home, mobile outpatient services are also not considered as part of post acute care based on Medicare’s guidelines.

Another big difference is that the billing is fee-for-service. So it’s more of a volume-based payment model than a value-based payment model. So the OT is paid per visit or per unit that is billed.

Patient Eligibility for Mobile Outpatient or OT in the Home

In terms of what patients are eligible to be seen by OT in the home or mobile outpatient, there really isn’t a limit. So patients are not required to be homebound. There also isn’t really the issue of like what we call a qualifying service in the same way that we talk about it in home health.

Now, of course, that being said, you obviously can’t bill for OT services if you aren’t providing OT. But there’s not any kind of requirement that they have to also be seen by nursing or also be seen by PT.

Can a patient receive home health and outpatient Services?

One thing that, though, is really important to keep in mind if you are working in this setting or if you are thinking about starting a a mobile outpatient clinic, is that if they are on traditional Medicare, meaning Medicare Part A and Medicare Part B, you cannot bill for outpatient or Medicare Part B services while the patient is on a Medicare Part A home health plan of care that includes, even if the patient is on home health only for nursing.

In these cases, it can be a bit tricky. Because, potentially you may be able to bill cash because they are not eligible to receive services under Medicare Part B, however, that can look a little bit funky because technically speaking, if it’s a skilled service that’s medically necessary that the patient requires, the home health agency is supposed to provide that due to the consolidated billing policy.

So, if you’re trying to argue that what you’re providing is skilled, but the home health agency claims it isn’t, it can create a somewhat awkward situation.

Always check if a patient is still on a home health plan of care

So it’s really important that you do your best to check the databases as to whether or not the patient is still receiving home health. Unfortunately, I’ve heard from providers that those are not always as up to date as they would like. Sometimes it can be helpful to ask the patient questions about is a nurse still coming to your home? Is someone coming, you know, to help you get dressed or bathed, those sorts of things. Because a lot of patients don’t always know that they’re on a home health plan of care under Medicare Part A.

Of course, we also want to be wary of instances, sometimes, where there is fraud from the home health agency where they may have kept this patient on just for occasional nursing visits for a significant period of time, which likely is no longer appropriate.

Billing Cash for OT in the Home and Mobile outpatient

Now, if you have a patient who is receiving Medicare Part A home health services, and they also want to be seen by you, a clinician who works for a mobile outpatient clinic or a similar setup, there are a couple different options. Potentially you could bill cash, but it’s best to only do that if it’s traditionally not a covered service. So if Medicare wouldn’t cover it even if they weren’t on Part A, that may be an opportunity to bill out of pocket. When I say cash, I’m not necessarily meaning like, you know, dollars and cents. I mean that they’re not using their insurance benefit.

Be a contractor for the home health agency

Your other option is to essentially work as a contractor for the home health agency. So the home health agency would pay you per visit based on whatever rate you establish with them, instead of the patient paying you. So there are a couple of different options. I am not necessarily the expert on negotiating those options.

However, it’s just important to be mindful that if your patient is still on a Medicare home health episode of care, under Medicare Part A, you cannot bill Medicare Part B for outpatient services. Medicare will eventually deny the claims and ask for that money back. And then unfortunately, you’re just kind of SOL because you can’t go and then recoup that money from your patient.

Join the Amplify OT Learning Platform today to gain immediate access to on-demand lessons and webinars to help you see the opportunities for OT in healthcare. Join us at amplifyot.com/membership today!

Reimbursement for Mobile Outpatient or OT in the Home

So let’s look a little bit more at reimbursement for mobile outpatient. Depending on the type of service you are providing will determine what reimbursement potentially looks like if you’re working with older adults.

So patients who are eligible for Medicare, so those are folks over the age of 65, people with ALS, ESRD, or with a disability, you cannot bill out of pocket for services that are covered under Medicare. You cannot opt out. You have to submit a claim for a service that would be covered by Medicare under their Part B plan.

And I do have an article that will go ahead and link for you in the show notes on opting out to understand that situation a little bit more. But what you need to know is that if it would be covered, you need to submit a claim to Medicare.

Partial coverage of an outpatient visit

There are also occasionally situations in where part of your visit may be covered and part of your visit may not be covered. This is especially true for folks who do home modifications. If you are doing like the functional assessment, completing a patient profile, right? Watching and observing how the patient functions in their home, watching them transfer those sorts of things, that is likely a billable service, something that is covered by Medicare.

However, if you are measuring doorways, if you are talking with a contractor, if you’re discussing tile materials and bathroom materials, that is not a service that is covered by Medicare. So you would not bill Medicare for that service.

Likely what you would have to do is kind of split the reimbursement where part of the visit would be submitted as a claim to Medicare and the other part would be something that the patient would pay for out of pocket.

So as you can see, the reimbursement is already getting a little bit funky.

Submitting a Claim for Mobile Outpatient Therapy

If you’re in a mobile outpatient clinic, you do kind of bill the same way that you would bill if you were working in a brick and mortar clinic where you’re using CPT codes. You still have to use the appropriate modifiers.

The main thing that may be different is that you may use a different point of service code. You may use the code 12 for home versus 11 for the office, but you always want to double check that with policies, reimbursement guidelines and other insurances.

Ad Break: Thanks for Supporting Amplify OT!

This is an affiliate link for PESI. This gets you the best price and supports the content you love on Amplify OT!

Billing Commercial Insurance

Now, if you’re doing mobile outpatient, whether or not you bill commercial insurance may also kind of be up in the air. Some do accept commercial insurance and others choose not to mess with it. You also want to be mindful of Medicare Advantage plans, which over 50% of Medicare eligible beneficiaries are on a Medicare Advantage plan. Sometimes you bill that just as if you were an out-of-network provider, where you’re able to bill the patient directly if you aren’t in network with that company. Other times you may still be required to submit a claim or provide the patient with a super bill or something like that.

So make sure to check the plan requirements for Medicare Advantage before assuming that you do not have to submit a claim to them. But for folks who aren’t on a Medicare Advantage plan, aren’t on traditional Medicare, who have a commercial insurance plan, generally speaking, you are able to charge them out of pocket for a service in the home, which is again very similar to how it would work if you had a brick and mortar clinic.

Mobile Outpatient Pediatric Therapy Services

This also applies if you are a pediatric company that is potentially seeing clients in the home, which is also increasingly popular. You want to be mindful of patients who may be on Medicaid, because oftentimes with Medicaid you may not be able to bill out of pocket for those patients, but if they’re on commercial insurance, you know, there are many pediatric clinics who decide not to take commercial insurance, and you could potentially bill out of pocket for those services as well.

There are some companies that do provide home health services through a home health agency to pediatric clients. They’re definitely not as prevalent as the Medicare Part A older adult home health agencies, but they do exist for pediatrics. But obviously the policies are very different because again, there is not necessarily a national policy. Many patients who are peds are on some sort of commercial insurance.

And then you’d also have to check with your individual state’s Medicaid plan to determine how exactly OT is provided and whether or not you would be able to see a pediatric client as an outpatient or bill them through an outpatient if they’re also receiving the home health benefit from a home health agency.

Because there may be some Medicaid plans that do not cover OT services underneath their home health benefit. So it just depends.

Join the Amplify OT Learning Platform today to gain immediate access to on-demand lessons and webinars to help you see the opportunities for OT in healthcare. Join us at amplifyot.com/membership today!

Submitting claims for home health vs outpatient

So I know I’ve thrown a lot of information at you in terms of reimbursement overall. Unfortunately, the answer is it depends. It is not as straightforward in terms of coverage as it is for a home health agency, especially if you’re a provider working in this setting.

For occupational therapy practitioners working for a home health agency, it’s very rare, unless you’re in a position of management or in a position of billing, that you would submit any kind of claim for home health that is generally going to be handled by the agency itself, a biller, those sorts of things versus if you work in mobile Part B, if you work in outpatient, you may be the one who is submitting the claim.

And obviously this definitely depends on whether or not you’re working for a larger company that has billers who submit the actual claims or if you’re working for yourself or if there’s just a couple of you who may be submitting the claims directly to the insurer. So it just depends.

But loosely speaking, OT in the home, you’re going to be much more hands on with the billing than you would if you’re working for a home health agency.

What OT Looks like in Mobile Outpatient and OT in the Home

And again, kind of what does OT look like in this space? It really depends. But loosely speaking, mobile outpatient clinics tend to be more specialized. So this tends to be home modifications. It can be lymphedema, it may be vestibular, you know, low vision, hand therapy, whatever it may be. But there may also be folks who are more generalized. But we do tend to see more specification or specialization in the mobile outpatient world because again, those do tend to be much smaller clinics than what we may traditionally see for a home health agency where folks tend to be a little bit more of a generalist.

Documenting for Home Health vs Mobile Outpatient Therapy

One of the last big differences in terms of kind of documentation regulation for home health versus OT in the home is that in home health you will have OASIS documents, which is their standardized patient assessment, versus in mobile Part B, you will not have any kind of OASIS or things like that because Medicare does not have a standardized assessment that must be administered to outpatient clients.

The only kind of standardized reporting that you might have in an outpatient setting would be if your company is large enough to bill MIPS. If there’s only one or two of you as providers, I almost guarantee that you are not going to be required to submit to MIPS. But if you work for a larger company like Fox Rehab or some of these other larger Mobile Part B providers, you may be required to submit data forMIPS.

Ad Break: Thanks for Supporting Amplify OT!

This is an affiliate link for PESI. This gets you the best price and supports the content you love on Amplify OT!

Summarizing the Difference of Home Health vs OT in the Home

So to kind of wrap things up between the difference of home health, OT and mobile outpatient or mobile Part B or OT in the home, whatever you want to call it. Under home health agencies, you’re generally going to be working as part of an interdisciplinary team. It’s reimbursed under Medicare Part A and OT is not a qualifying service and the patient needs to be what is considered homebound. It’s reimbursed under PDGM, which is considered a value based payment model because it kind of functions similar to a bundled payment where each service isn’t reimbursed separately.

Versus mobile OT, OT in the home, mobile outpatient, you will generally not be working as part of an interdisciplinary team. These tend to only have one discipline or you may only have like OT and PT or OT and speech.

You are billing per visit based on timed codes. So these are generally not going to be a bundled payment. They’re going to be fee for service.

Summarizing Eligibility Differences

There’s also not the same kind of eligibility requirements where a patient would need to be homebound or would need what we’d call like a qualifying service. So the flexibility of who can receive mobile outpatient services is much broader than who can receive home health services.

So both of these important settings really serve an important role in our profession and offer distinct types of services for our clients or patients. But if you’re going to consider working as OT in the home or you’re considering a career in home health, if you’re. It’s important to understand these differences because what your job may look like will be potentially very different.

Amplify OT Resources for Home Health and Outpatient

And if you’re interested in diving into outpatient services or home health further, we have so many resources on AmplifyOT.com, as well as in the Amplify OT Learning platform, which we have links in the show notes.

Amplifyot.com/homehealth is where we have all of our home health resources and again, I’ll also make sure that that is linked in our show notes. So thank you so much for listening. Please let me know if you have any questions and I hope you have a fantastic rest of your day and leave with a little bit more knowledge on the difference between home health and OT in the home.

All right, I’ll chat with you next time.