The role of a home health nurse, nursing aide, physical therapist or medical social worker is to visit a patient in their home, conduct a treatment, evaluate their health issues and create a plan for treatment. Clinicians who visit patients in the home are usually paid on a per-visit rate. Often the agency that hires these clinicians will pay them a determined amount per visit, no matter how many patients they visit or hours they work in a workweek.


So, is this considered “piecework” or “payment on a fee basis”?


It might sound like piecework, which would lead you to believe that these nurses are eligible for overtime pay if they work more than 40 hours per week. So why is this type of pay considered exempt from overtime rule on the federal level?


There is something to consider: each home visit is unique.


Each time a nurse visits a home, they must respond in a different way. Sometimes it might require drawing blood, dressing wounds or giving an injection, or sometimes it might involve having a discussion with family members about the care of their loved ones.


They use their professional experience to determine what needs to be done, which is why this type of work is considered to be a “pay on a fee basis” job, compared to the piecework payment to non-exempt-from-overtime workers who perform an indefinite series of identical, repeated jobs.


While this is the case according to the federal government, there are exceptions in certain states – which we will explain in further below.


How Home Health Per Visit Pay Works

Often these rates are not set by the home health agency, but rather by the private insurance company or the government agency (such as Medicaid or Medicare). For example, the pay rate per visit for a home health aide varies, but it is usually between $30-$60 per visit.


Sometimes nurses are paid more for the first visit, as it takes time to complete all of the required paperwork. However, regardless of how much time it takes to complete the paperwork or perform other duties related to the job, the nurse is paid only the set fee for each in-home visit.


Per-visit pay for registered nurses has been a very popular method of payment and many agencies treat these nurses as exempt from minimum wage and overtime pay. The home nursing care companies that pay nurses in this way don’t track hours – they only determine pay by the number of visits made.


This has the inherent incentive of encouraging nurses to make more visits in order to earn more. (However, it could have the negative effect of encouraging nurses to spend less time with each patient and offer less helpful and individualized care.)


Home Health Nurses, Per Visit Rates and Overtime

In a decision made by the U.S. District Court of Ohio, registered nurses who were paid on a per-visit basis fell within the professional exemption from minimum wage and overtime pay that is established within the federal Fair Labor Standards Act (FSLA). This decision has been appealed, but it is the first court decision to address whether or not registered nurses who are paid on a per-visit basis would be exempt from overtime pay and minimum wage.


The FLSA determines whether or not employees are eligible for overtime pay based on specific criteria. The burden is on the employer to prove the requirements for the exemption. There are many exemptions for “professionals” that include the level of education and the type of work done.  


One of the requirements for this type of “white collar” overtime exemption is whether or not the registered nurse is under “fee basis of payment.” This refers to a payment that is made for an agreed sum for a single, unique job (as opposed to a series of jobs that are repeated.)


So, when a nurse visits someone in their home, is this a unique task or is it one in a series of jobs which is repeated an indefinite number of times for which identical payments are made? This is what needs to be determined, as professional employees paid on a salary or fee basis are exempt from the overtime requirements of the law.


Cleveland Clinic: A Case Study

An example of this in action is the case of Cleveland Clinic Healthcare Ventures in Valley View, Ohio. Four registered nurses sued the clinic for overtime compensation.


These registered nurses provided home nursing services to patients. They were responsible for managing home care visits, examining patients, developing a plan of treatment and much more. The nurses were expected to make 25 home visits per week, as well as having 15 hours per week of time when they were expected to be on call.


The nurses were paid for their work on a set per-visit rate. They were paid $32 per visit during the beeper call scheduled weeks and $30 per visit when not scheduled. This covered everything associated with each patient visit, including scheduling treatment, travel time and documentation.


The nurses explained that they regularly did more than 25 visits per week and worked between 55 and 65 hours – sometimes as much as 80 hours per week. They sued Cleveland Clinic, as they felt they were due overtime compensation under the FLSA for the hours that they worked in excess of 40 hours per working week.


However, the decision of the court was that they were not eligible for overtime pay. The court found that the jobs that the nurses performed were “unique.” The nurses testified that their job required them to give a unique assessment to each individual, then develop and implement a plan of care. They had to take into account many different factors, including the patient’s medical history, their home and family situation, their mental status and much more.


They were not merely performing a set “job” many times over – they were required to apply their judgement and professional skills to every unique patient situation. Because they were applying professional skill and judgement to each visit, the nurses were considered to be professional employees and it was determined that they were not entitled to overtime compensation under the FLSA.


However, while this may be the case in Ohio, the state laws are not the same across the USA.


Federal Laws vs. State Laws: Some States Must Pay Overtime

Although the federal laws in the USA do not consider this type of work eligible for overtime, there are some states that do. For example in California there are many home health care companies that are being hit with lawsuits because they have not paid overtime to their pay-per-visit clinicians.


Some of the other states in the USA that have protected the right to overtime pay for home health care workers include Illinois, Colorado, Maine, Massachusetts, Washington, Pennsylvania and Wisconsin.


If your business is situated in one of the states where pay-per-visit employees are eligible for overtime, you will need to pay them overtime wages if they work more than 40 hours per week. Be sure to look up the specific laws as they apply to the state where your business is located.


Overtime Tracking for Home Health Care Employees

In a state where home health care employees are entitled to overtime pay, it’s very important to keep track of employee hours so that overtime pay can be calculated correctly. However, this can be very challenging when nurses are traveling to different locations throughout the day.


One of the most effective ways to do this is to use a mobile time clock app such as Boomr for Healthcare, which is designed with functions specifically for home care clinicians. Not only can the app be used to keep track of overtime hours for fee-basis employees (who receive a fixed amount of pay for each visit made), it also offers a number of other features.


Employers will be able to set up all clinicians with custom visit and non-visit codes and will be able to assign pay rates for each type of visit. Unique pay rates can be set for weekends, after hours and on-call hours. The app tracks employees with GPS, so it is easy to see where nurses are visiting patients throughout the day. The app can even be used to track employee expenses such as parking and mileage, as well as to compare actual visit durations to the target.


Rather than using a generic time tracking app, this option is specifically designed for the healthcare industry and uses industry specific terminology, phrasing and features. It’s a much more reliable and efficient way for home visit nurses to track their hours, especially compared to other traditional methods such as paper timesheets.


Do You Hire Nurses on a Pay Per Visit Basis?

If your agency works with home care nurses on a pay per visit basis, it is important to keep the follow pointers in mind.


  • The burden of proof is on the employer to ensure that the the nurse meets the exemption from overtime pay.
  • You will need to prove whether or not the nurse performs a series of jobs that are the same, or whether they perform a unique job each time that requires their professional expertise and judgement.
  • Keep in mind that even if a registered nurse is exempt under federal law, they may still be entitled to overtime pay when it comes to state law.
  • If your business is based in a state where pay-per-visit healthcare employees are paid overtime, a time tracking app can be extremely useful in keeping track of the total hours worked.


If your payment structure is incorrectly implemented, this could lead to issues with FLSA disputes, so be sure to check the requirements carefully.