What must a physician do in order for a Medicare patient to receive home health care?
certify the need for services and establish a POC
What must the beneficiary meet in order to qualify for home health care through Medicare?
must meet Medicare's definition of homebound
What is Medicare's definition of homebound?
It requires a "taxing effort" for the patient to leave their home (ex. extra assistance needed to leave)
Would a person who needed to use a drive-thru for their meals rather than prepare a meal at home be considered homebound by Medicare's definition?
Yes, it is a "taxing effort" for the person to cook their own meals
What determines if a patient is considered homebound by Medicare's definition?
Practitioner's supportive documentation (nurses, PTs, etc.)
Where must the care be provided?
in the patient's place of residence
Is assisted living a place of residence to receive home health care?
Is an adult-day care a place of residence to receive home health care? SNF?
No, they should provide the care
What 3 reasons that a beneficiary could leave their home and not lose their home health care 5 years ago?
2. Hair appointment
3. Doctor's appointment
What must a home health agency be in order to serve Medicare patients?
What part(s) of Medicare cover home health? What is the coverage?
Part A and B
Part A = 100%
Part B = 80:20 coinsurance
Can a home health agency waive the patient's 20% co-insurance responsibility?
No, it is illegal
How is home health care prescribed?
If a patient needs skilled nursing on intermittent basis or PT or SLP or has continued need for OT once one of the other skilled disciplines has established a POC
What skilled discipline cannot establish a POC for home health care?
OTs--they missed the boat to lobby!
They can continue their care once a POC is started by either skilled nursing, PT or SLP even if all others end.
What disciplines can establish a POC or fill out an OASIS for home health care?
PTs, SLP and skilled nursing
What discipline does most of the evaluations for home health care?
PTs do 40% of the evals
What other services may physicians order for home health care once a POC has been established? (3)
3. Home health aides
What is happening with the cost of home health care today and why?
Raising due to the baby boomers
How does Medicare see home health care agencies?
As the gatekeeper to keep patients out of the hospital
What may prevent a home health agency from sending out a skilled nurse every time to establish a POC?
Medicare will not reimburse for a 1 time visit--must have an ongoing nurse need initially (i.e. wound or dialysis); otherwise, agency will send out PT or SLP
What is the overall % of home health services through Medicare?
What is a case mix index?
A scale that measures the relative difference in resource intensity among different groups in a clinical model (has 3 domains)
What is a scale that measures the relative difference in resource intensity among different groups in a clinical model?
Case mix index
What determines the case mix index?
What are the 3 domains of a case mix model from the OASIS?
What entails the clinical domain from the OASIS (case mix model)?
Diagnosis, medication, vision, pain, wound, incontinence, dementia and dyspnea, etc
What entails the functional domain from the OASIS (case mix model)?
How independent the person is at home (i.e. bathing, toileting, transferring, locomotion, upper/lower dressing)
What entails the service domain from the OASIS (case mix model)?
The person that does the OASIS (PT, SLP, nursing) predicts how many of each skilling service pt will need (intensity each patient requires or frequency of care needed)
What is Conditions of Participation (CoPs)?
The minimum health and safety standards that a HHA must comply with in order to qualify for reimbursement under Medicare
What is term for the minimum health and safety standards that a HHA must comply with in order to qualify for reimbursement under Medicare?
Conditions of Participation (CoPs)
What state agency surveys HHA to make sure they are meeting CoPs and handles public complaints?
How is ODH involved with HHAs?
Surveys HHA to make sure they are meeting CoPs and handles public complaints
What is all included in the prospective payment system rate of home health care consolidated billing to Medicare? What are 2 exceptions?
An individual under a home health POC payment for all services and supplies (i.e. wound dressing supplies, catheter supplies and any outpt therapy including specialists) provided in the home
OP drugs and DME
Similar to a benefit period, how many days are within 1 episode of home health services?
What is required after 60 days or 1 episode expires for skilled services?
Re-certification by doctor for additional skilled services
What is a HHRG?
(Home Health Resource Grouper Patients) all receiving 5 or more visits under Medicare are grouped into 1 of 53 groupings based on clinical, functional and service domains as measured by OASIS
What term is all those receiving 5 or more visits under Medicare are grouped into 1 of 53 groupings based on clinical, functional and service domains as measured by OASIS?
What is a LUPA?
(Low Utilization Payment Adjustment) occurs when HHA does not deliver 5 or more visits to the patient
What is the term for when a HHA does not deliver 5 or more visits to the patient (i.e. patient goes back into the hospital within 4 days)?
LUPA (Low Utilization Payment Adjustment)
How is a LUPA paid for?
On a per visit basis as opposed to HHRG (i.e. $125 per visit/1.5hrs)
What is a HHA viewpoint of LUPAs
Find it more financially rewarding if they see patient for more than 4 days
What is an OASIS?
(Outcome and Assessment Information Set) comprised of both interview and observation that is critical for reimbursement and measuring outcomes, assessment and POC
What form is comprised of both interview and observation that is critical for reimbursement and measuring outcomes, assessment and POC?
OASIS (Outcome and Assessment Information Set)
When is an OASIS collected?
1. SOC (start of care)
2. Transfer visit
3. ROC (resumption of care)
4. Re-certification for a new episode
How does Medicare utilize the OASIS for serving the public?
Gives public access in HomeCare Compare where all certified HHA have their outcomes compared for public viewing
What form is used for discharging home health care patient?
Abbreviated OASIS (shorter version that is not as intensive)
Who uses the OASIS and how are they received by Medicare?
Used by skilled clinicians in the home and are collected at key times
When did CoPs mandate the use of OASIS?
What was the reimbursement system like prior to 2000 for home health care?
Based on per visit rate
What year did home health compare launch?
In 2006, what did MedPAC (Medicare Payment Advisory Commission) recommend?
Larger scale revision of OASIS
What did OASIS-C capture in 2010 in addition to patient outcomes?
HHA's timeliness and process measures
What year did the OASIS data become a condition of payment?
What are some outcome measures the public can see with HHA improvements? (10)
3. Oral medications
5. Pain interfering with activity
7. Urinary incontinence
9. Emergent care/acute hospitalizations
10. D/c to community
What determines the money a HHA will be reimbursed?
What could a HHA receive if it does not report quality standards?
2% penalty reduction in payment if not participating
What are outliers in the sense of home health care payments?
Payments made in addition to regular 60 day case mix and wage adjusted episode payments for case episodes that incur unusually large costs due to home health care needs
What are payments made in addition to regular 60 day case mix and wage adjusted episode payments for case episodes that incur unusually large costs due to home health care needs?
What is a partial episode payment (PEP)?
Partial payment adjustment given to HHA when a patient has been discharged and is readmitted with a new SOC within original 60 day episode (eliminates paying 2 places)
What is a partial episode payment a form of?
Prospective payment system
What is a RAP and how does it work?
(Request for Anticipated Payment) once SOC is completed and HHRG is calculated, HHA requests payment from Medicare based on anticipated delivery of service
Medicare pay 60% up front and reconciles the other 40% once the episode is complete with d/c
What does the RAP system allow the HHA to do?
Allows HHA to request payment based on case-mix or HHRG score rather than waiting 60 days (will get some money up front)
What 4 criteria must referrals contain to certified HHAs?
1. Physician order
3. Pay source (Medicare Part A or B)
4. If referred from hospital, SNF or rehab facility, a continuity of care signed by physician
What government insurance does not require a patient to be homebound to qualify for home health care?
Is there a limit to the number of agencies Medicaid reimburses for home health care?
No, can pay for skilled and custodial care from 2 different agencies unlike Medicare which requires bill consolidation
What type of insurance is usually more restrictive with reimbursement for home health care?
Commercial care (i.e. pt is not homebound if she/he can ambulate >60ft or navigate stairs with Mod A)
What is critical for commercial insurances to reimburse home health care?
Medicare payment under the HHPPS is based on what?
A national standardized 60 day episode payment adjusted for case mix index and wage index (this is what describes the patient)
What amount does Medicare pay for home health care services?
A fixed amount for all services rendered under 60 days on a HHRG calculation
What must HHAs strive for?
The best outcome while being prudent in deliver of services (diff reimbursement rates based on geographical locations)
What 2 categories are PPS episodes classified?
1. Early (episode 1 or 2 based on 60 days in series)
2. Late (episode 3 or more based on 60 days in series)
The minimum therapy threshold includes how many visits?
How many visits set a higher therapy case mix adjustment thresholds?
14-19 visit threshold
Over 20 visit threshold (will be reimbursed more for higher score)
What is the current amount of HHRG codes?
What is being adopted as a result of episode timing and therapy classification changes?
A four equation case mix model
HHRG score of C0F0S0 vs C3F3S3, which score will be reimbursed more?
C3F3S3 based on clinical, functional and service domains for a 60 day episode
What are 2 prerequisites for submitting a RAP?
1. Verbal order or signed continuity of care from physician
2. At least 1 billable visit
Can you submit a RAP on 1st visit?
What 2 factors can influence the final 40% payment reimbursement from Medicare to HHAs?
2. Incorrectly projecting the number of therapy visits (i.e. PEP)
What must a HHA have signed prior to final bill submission?
485 POC to receive 60/40
What is the payment up front and at end of episode when a patient is re-certified for 2nd episode of home health care?
50% up front and then 50% at end of 60 day period
What are 2 scenarios where a PEP would occur?
1. Patient transfers from HHA to another HHA
2. Patient is readmitted to the same agency within 60 days of initial SOC
Payment is prorated proportionately to the amount of time elapsed in 60 days
How is the PEP adjusted?
Payment is prorated proportionately to the amount of time elapsed in 60 days
What is a SCIC and what needs to be used?
(Sudden Change in Condition) OASIS must be used if pt's condition changes that would give a different HHRG score
What would happen if a HHA used SCICs often?
Would be red flagged by Medicare
Prior to 2008, what % of "high" therapy cases ended with 10-13 visits?
more than 50% (moved to tier model)
What does RAC stand for? What is their mission?
Recovery Audit Contractors
Mission is to detect and correct past improper payments and can reopen claims up to 3 years from date claim was paid
What are not included as time on the MDS?
1) Initial evaluation
2) Documentation time
3) Group Tx over 25% of min/wk or with more than 4pts per PT or PTA
PTAs require what kind of supervision?
1) No initial eval
2) Periodic supervision
To receive 100% medicare coverage for HC benefits these 6 conditions must be met:
1) Eligible Medicare Beneficiary
2) Physician signs off on Rx and POC
3) Must be homebound
4) Tx must be in place of residence
5) Must be a certified HHCA
6) Pt must need skilled nursing services on an intermittent basis OR SLP or PT or continued need for OT
Scoring thresholds for the case mix index?
1) 0-13 visits
Grouping pts by level of intensity are based on?
1) Total minutes of therapy/wk
2) Days of therapy/wk
3) Number of types of therapy