Specialty Solutions Spotlight: When Home Health Referrals Need a Closer Look

How do I know when a home health claim needs a different level of care?

Home health can be a critical part of recovery, but it should not run on autopilot. The issue for adjusters is knowing when the ordered services no longer match the injured employee’s current needs, recovery progress or claim goals. A closer look can prevent unnecessary service hours, prolonged dependency and care that is either too much or too little for the situation.

Your specialty care coordinator should review the physician’s order, assess the requested service level, coordinate the right type of care, evaluate whether durable medical equipment could reduce hands-on support and keep the claims team informed as care continues.

What to Look for in a Home Health Referral

Home health services include skilled nursing, home health aide support, companion care, homemaker services and durable medical equipment. Each one serves a different purpose.

For adjusters, the key question is not only whether home health is needed. It is whether the current level of care fits the injured employee’s medical condition, mobility, functional limits, home environment and ability to complete daily activities.

A home health referral should include a physician-prescribed plan of care. The plan should explain the injured employee’s condition, the services ordered, the goals of care, the expected visit frequency and any safety precautions.

A referral needs a closer review when:

• Services continue without clear recovery goals
• The same level of care remains in place after the injured employee improves
• Multiple caregivers are ordered without a clear explanation
• Skilled nursing continues when the need appears to be non-medical support
• Caregiver notes do not show progress toward independence
• The injured employee or family caregiver has not received training on equipment, medication administration or daily care tasks

Warning signs do not always mean the services are inappropriate, but they do mean the claim would benefit from a review before the care plan keeps moving forward unchanged.

Why the Level of Care Matters

The right care level can support safety, recovery and independence. The wrong care level can create avoidable problems for the claim.

If the level of care is too high, the claim can carry unnecessary cost and make the injured employee more dependent on caregivers for tasks they could safely resume.

If the level of care is too low, the injured employee faces safety risks, delayed recovery or avoidable complications.

Adjusters should evaluate whether the ordered service matches the current need. That means confirming that skilled nursing is appropriate, identifying when a licensed practical nurse or home health aide could be a better fit or determining whether companion or homemaker services are enough for nonmedical support.

When Independence Should Be Part of the Plan

Home health should help the injured employee move toward safe self-care when possible. It should not continue without a clear purpose or progress marker.

Adjusters can look for documentation that answers three questions:

1. What is the injured employee expected to do next?
2. What progress has been made since services began?
3. What needs to happen before services can be reduced or ended?

If the answers are unclear, it’s time to ask whether the care plan should be updated. Apricus can support that review by coordinating with the treating physician, case manager and claims team to clarify the care plan, service frequency and next steps.

When Equipment Reduces Service Hours

Durable medical equipment can reduce the need for ongoing caregiver support. Lift systems, specialty beds, traction equipment, chairs and motorized wheelchairs help an injured employee move more safely and complete daily activities with less support. The right equipment supports independence while managing claim cost. It also reduces the need for multiple caregivers in the home.

Apricus can evaluate whether equipment, caregiver training or a lower level of service could safely meet the injured employee’s needs. That gives the adjuster a clearer path for determining whether the current care plan still makes sense.

When Home Health Deserves a Second Look

• A hospital discharge includes several home health orders
• The requested care level seems higher than the documented need
• Services continue without clear progress updates
• Skilled care is ordered, but the need appears to be daily living support
• The claim involves complex medical needs, mobility limits or safety concerns
• The injured employee needs durable medical equipment
• The treating physician’s order needs review for service level, frequency or duration
• The claims team needs clearer updates on what is happening in the home

Home Health With Apricus

Apricus works with credentialed home health care providers and coordinates services based on the injured employee’s needs. Care coordinators are available 24 hours a day to accept referrals and work with adjusters, case managers and discharge planners on a customized assessment and action plan. 

Apricus coordinators: 

• Match the care level to the injured employee’s current condition
• Review whether the requested frequency and duration are appropriate
• Identify when a licensed practical nurse, home health aide, companion or homemaker is the right fit
• Evaluate whether durable medical equipment could reduce hands-on care needs
• Support communication among the physician, case manager and claims team
• Provide actionable updates as treatment continues

For adjusters managing busy caseloads, the benefit is clarity. A strong home health referral process confirms what care is needed, what can be adjusted and what information the claims team needs next.

Home health helps an injured employee recover safely after a hospital discharge, surgery or serious injury. But when services continue without review, the claim can drift. When adjusters know what to look for, injured employees receive the right support at the right time while keeping the claim moving with a clear purpose.

This information is meant to serve as a general overview, and any specific questions should be fully reviewed with a health care professional or specialty service provider.

To make a referral for specialty products and services, call 877.203.9899 or email apricus.referrals@enlyte.com.