Home Health Agencies up in arms over new Medicare regulation

The following is an article written by Phil Galewitz Kaiser Health News.

Home health agencies, hospitals and consumer groups are complaining that a new rule intended to curb unnecessary Medicare spending will make it harder for senior citizens to get home care services.

Under the requirement, which is to take effect Friday, Medicare beneficiaries will have to see doctors 90 days before or 30 days after starting home health services in order for the home health agencies to be reimbursed. Those face-to-face visits may be a burden for some home-bound frail seniors, as well as those who live in rural areas, the industry says.

Some Medicare experts have little sympathy for industry complaints.

"Home health is a benefit that is out of control," said Dr. Robert Berenson, a health policy expert at the Urban Institute.

Medicare home health care typically consists of services such as skilled nursing, physical therapy and speech therapy. Unlike most services in Medicare, patients don't have co-payments or deductibles. The services can be prescribed for 60 days at a time, although there's no limit on the number of times they can be renewed.
Medicare home health costs doubled to $19 billion from 2002 to 2009. Cases of Medicare fraud also have been rising, and federal officials have launched a crackdown that includes prosecuting home health agencies that bill for services that weren't provided.

Under current law, doctors must prescribe home health care for patients to receive services, but the physicians don't have to see the patients to make that determination.

Medicare advisers to Congress say the regulation doesn't go far enough to reduce waste and fraud because it allows patients to start getting home health services before first seeing doctors to ensure that they need it.

"Such a large window ... does not ensure that beneficiaries receive an examination in a timely manner before home health care is delivered," the Medicare Payment Advisory Commission wrote in a report to Congress this month. Berenson is a member of the commission.

The doctor-visit rule, which was included in the health care overhaul, initially was to take effect Jan. 1 and was to require providers to see patients within 30 days before or two weeks after the start of home care. In December, the Centers for Medicare and Medicaid Services delayed implementation until April because of complaints from providers, who claimed that the rule was too stringent and most doctors were unaware of the change. At that time, the CMS also announced that it was expanding the time frame for patients to meet with doctors.

Now a coalition of home health industry, hospital and doctor groups and the AARP is pushing for another three-month extension.

CMS spokesman Tony Salters said the agency was listening to concerns, but he refused to say whether another extension will be granted. Salters said the agency didn't have any data to show what percentage of Medicare patients now got home care services without having recent visits with their doctors.

"There is a lot of confusion out there, and patients may lose access to their care," said Nora Super, an AARP lobbyist.

Dr. Roland Goertz, the president of the American Academy of Family Physicians, said the new rule added documentation requirements for physicians. "It makes our paperwork burden even more onerous," he said.

Under the rule, doctors would have to fill out forms that certify that they or other health care providers such as nurse practitioners had seen patients for the specific purpose of determining the patients' needs for home care. This would be in addition to doctors' current duties of prescribing home health care and signing off on care plans, which the home health agencies typically develop.

"A home health face-to-face encounter contradicts the purpose of home health care," Hoosier Uplands Home Health Care & Hospice in Mitchell, Ind., a rural area about 85 miles south of Indianapolis, wrote the CMS last year. "This would impose on the patient the need to leave home for increased and unnecessary physician visits."

But the home health agency voluntarily has tried out the new rule over the past three months and found only minor problems, such as doctors not filling out forms correctly, said Melissa Jeremiah, the director of operations for Hoosier Uplands.

Rochelle Archuleta, a policy expert at the American Hospital Association, said her organization was "hearing concerns from providers ... and that tells us this policy is not ready for enforcement." Hospitals are worried that patients who are discharged may not be able to get home health services immediately and hospital-owned home health agencies may have trouble complying with the law.

Home health agency groups said they understood Medicare's need to reduce unnecessary care but that the new rule was too onerous.

"We want to make sure beneficiaries who really need the services are not denied it," said Peter Notarstefano, the director of home and community-based services at Leading Age, which represents nonprofit home health agencies