Home Care Pay-Per-Visit: How Agencies Get Paid & Stay Profitable in 2025
Key take-aways
- Pay-per-visit (PPV) means the agency is reimbursed a flat amount for each skilled or personal-care visit it delivers—not by the hour and not by the 30-day episode.
- PPV still exists across all major payer classes (Private-Pay, Medicare, Medicaid, Private Insurance, VA & state waiver programs), but rules, rates, and cash-flow timing differ dramatically.
- In 2025 the national Medicare PPV rates range from $78.20 for a home-health-aide visit to $276.85 for medical-social-work, while states such as Illinois pay about $111 per skilled-nursing visit under Medicaid.
- Building a PPV strategy requires accurate capitalization, airtight billing workflows, and productivity targets that protect your margins even when visit counts fluctuate.
1. What exactly is “home care pay per visit”?
Pay-per-visit is a reimbursement methodology in which a payer sets a fixed fee for each completed visit by discipline (RN, PT, OT, aide, etc.). It differs from:
| Model | How you’re paid | Typical payers | Cash-flow speed |
|---|---|---|---|
| Hourly / shift | $X per hour worked | Private-Pay, some Medicaid PCS | Immediate at point-of-service |
| Episode (PDGM) | Bundled 30-day amount adjusted for case mix | Medicare, MA plans | 2–3 weeks after RAP/final claim |
| Pay-per-visit | $X per completed visit | Medicare (LUPA), Medicaid FFS, many commercial plans | 14–45 days after clean claim |
For new agencies, PPV is often the first sustainable revenue stream because you can start small, measure productivity visit-by-visit, and avoid the cash-flow lags of episode-based billing.
2. How each major payer handles PPV
Private Pay
- Structure: Usually billed as a flat in-home assessment fee or a la carte task visit (e.g., wound check, medication set-up).
- Rates: Highly market-driven. Many agencies charge $65–$150 per RN visit and $30–$60 per aide visit, aligning with local wage levels and competitor pricing.
- Cash flow: Paid at or immediately after service—no payer approvals, making it the fastest way to generate working capital.
Medicare (Traditional Part A)
- Standard rule: Medicare now pays bundled 30-day episodes under PDGM, unless the patient is Low-Utilization Payment Adjustment (LUPA).
- 2025 national PPV rates (quality-data-submitting HHAs):
- Home-Health Aide (HHA): $78.20
- Skilled Nursing (SN): $172.73
- Physical Therapy (PT): $188.79
- Occupational Therapy (OT): $190.08
- Speech-Language Pathology (SLP): $205.22
- Medical Social Work (MSW): $276.85
- Enrollment timeline: Plan for 11–18 months from start-up to first Medicare payment.
Medicaid
- Fee schedules are state-specific. Many states reimburse a single PPV amount for each discipline.
- Example: Illinois Medicaid pays $111 per skilled-nursing, therapy, or aide visit in 2024–25.
- Trends: Roughly a third of states boosted home-care rates in 2024 to address workforce shortages.
Commercial & Medicare Advantage Plans
- Often mirror Medicare’s PDGM/LUPA rules, but negotiate your own per-visit rates.
- Credentialing can take 90–180 days; some carriers require six months of outcomes data before contracting.
Veterans Affairs & State Waiver Programs
- VA Homemaker/Home-Health Aide benefits usually pay hourly, but VA Skilled Home Health uses the Medicare fee schedule minus a small discount.
- HCBS waivers pay PPV or bundled daily rates—valuable for agencies targeting long-term clients with stable needs.
3. Building a pay-per-visit business plan
- Define your service mix. High-margin skilled visits (RN/PT) offset lower-margin aide visits.
- Set productivity benchmarks. Aim for 5–6 billable RN visits or 6–8 aide visits per field employee per day.
- Price private-pay visits competitively after mapping local competitor rates and labor costs.
- Model cash flow. Assume a 30-day AR cycle for Medicare/Medicaid PPV and 3-day cycle for private-pay cards.
- Capitalize accordingly. Budget at least six months of payroll and overhead before reimbursements stabilize.
4. Billing & revenue-cycle safeguards
| Step | Best practice |
|---|---|
| Intake & eligibility | Verify payer coverage and service authorization before the first visit. |
| Documentation | Complete visit notes in your EMR same day; missing signatures = denied claims. |
| Coding | Use correct revenue codes (e.g., G0299 for RN, G0156 for aide) and attach OASIS where required. |
| Claim filing | Submit within 5 days of visit to shorten DSO. |
| Denial follow-up | Track every remit; appeal within payer timelines to avoid revenue leakage. |
A specialized home-health RCM partner typically costs 2–5% of collected revenue, far less than the write-offs caused by DIY errors.
5. Profitability snapshot (Skilled-Nursing PPV example)
| Daily SN visits | Medicare pay-per-visit (2025) | Average RN labor & overhead | Gross margin per visit | Daily gross margin |
|---|---|---|---|---|
| 5 | $172.73 | $110 | $62.73 | $313.65 |
| 8 | $172.73 | $110 | $62.73 | $501.84 |
| 10 | $172.73 | $110 | $62.73 | $627.30 |
6. Compliance & audit watch-outs
- Plan of Care alignment: Medicare auditors recoup if visit frequency exceeds MD orders.
- Visit verification (EVV): Mandatory for Medicaid personal-care and, in many states, skilled visits.
- Quality-data submission: Failing HHVBP or QRP reporting cuts your Medicare PPV rates by 2%.
FAQ
How does a home health agency get paid under the pay-per-visit model?
By submitting a clean claim for each completed visit, coded to the correct discipline. Payment arrives once the payer adjudicates—immediately for private-pay, 14–45 days for insurers.
Is pay-per-visit still allowed with PDGM?
Yes. Low-utilization periods (LUPAs) are always paid per visit, and many Medicare Advantage and Medicaid plans keep PPV for all cases.
Can I bill private-pay clients per visit instead of per hour?
Absolutely. Many agencies bundle tasks into a 60-minute RN “wellness check” or a 90-minute aide “ADL support visit” and charge a flat fee.
Which payer pays fastest?
Private-pay credit-card or ACH transactions at point-of-care. Among insurers, Medicare EDI claims with EFT usually fund within 14 days once you’re established.
What cash cushion do I need?
Most start-ups set aside $75k–$150k to cover payroll, accreditation, and overhead during the 11–18-month Medicare enrollment runway.
Ready to launch—or tune up—your pay-per-visit revenue?
CarePolicy’s licensing and revenue-cycle team helps agencies across all 50 states design payer mixes, negotiate PPV contracts, and streamline billing so you get paid fully and on time. Book a free strategy call and turn every visit into predictable cash flow.
Written for the CarePolicy.us resource center, May 30 2025.