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College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIPFrequently Asked Questions About Home Health Services
While the conditions outlined in this Q&A pertain specifically to Medicare, they can be used as a general guide to determining your patient's eligibility for home health care services under most insurance plans. In many instances, if your patient does not meet the Medicare conditions, home health services will likely not be covered by their insurance carrier. As in any case, however, all insurance companies have different requirements.
Q1. I have been asked to certify that my patient needs home health services. What am I certifying?
A1. To qualify for home health care coverage, you must certify that your patient meets the following conditions:
1. Your patient needs medical care in their home and you have certified a plan of home care for him/her;
2. The care your patient needs includes intermittent (not full time) skilled nursing care, physical therapy, or speech language pathology services;
3. Your patient is homebound; and
4. The Medicare program has approved (certified) the home health agency serving your patient.The home health agency has the additional burden of assessing the patient status and environment of care. The information is then evaluated to determine the type of home health services that would best meet the patients needs. The home health agency should then contact you with these recommendations to assist you with the development of a Plan of Care.
Q2. Am I really responsible for finding out all of that information?
A2. You are responsible if you certify that your patient is homebound. If you carelessly or deliberately certify a patient is homebound when they are not (and you should have known that they were not) then you may cause a "false claim" to be submitted to Medicare or Medicaid. This could subject you to criminal prosecution, civil penalties and exclusion from participation in the Medicare and Medicaid programs.
Q3. Can a Physician Assistant or a Nurse Practitioner certify a plan of care for home health services?
A3. No, Physician Assistants and Nurse Practitioners may NOT sign orders for home health services.
Q4. When is an individual homebound?
A4. An individual does not have to be bedridden to be considered homebound. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
Generally speaking, patients are considered homebound if they have a condition (due to an illness or injury) that restricts their ability to leave their place of residence, except with the aid of a supportive device such as crutches, canes, wheelchairs, and walkers, the use of special transportation, the assistance of another person or if leaving home is medically contraindicated. In most circumstances, if a patient drives, he/she would not be considered homebound.
Please note that the homebound criteria are not met when: (1) frequent absences from the home are for social reasons, for shopping or business purposes; or (2) the patient attends adult day care for non-medical reasons.
Q5. What are some examples of homebound patients?
A5. Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists include:
1. A patient recently paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk;
2. A patient who is blind or senile and requires the assistance of another person to leave his/her residence;
3. A patient who has lost the use of his/her upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave his/her residence;
4. A patient who has just returned from a hospital stay involving surgery suffering from resultant weakness and pain and, therefore, his/her actions may be restricted by his/her physician to certain specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.;
5. A patient with arteriosclerotic heart disease of such severity that he/she must avoid all stress and physical activity; and
6. A patient with a psychiatric problem if the illness is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe to leave home unattended, even if he/she has no physical limitations.
Q6. What if the patient is able to leave the home?
A6. If the patient does in fact leave the home, the patient may still be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive medical treatment. Occasional absences from the home for non-medical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain health care outside the home.
Q7. What is considered the patient's place of residence?
A7. A patient's residence is wherever he/she makes his/her home. This may be his/her own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, a hospital, skilled nursing facility (SNF), or intermediate care facility (ICF) are not considered the patient's home.
Q8. What about elderly or feeble patients who are afraid to leave the home?
A8. The aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless he/she meets the conditions outlined in Question #1 above.
Q9. Who makes the homebound determination?
A9. Determinations concerning medical necessity or homebound status are the responsibility of the medical professionals treating the patient. The home health agency can assist the medical professional in making eligibility determinations and in understanding the standards governing home health coverage criteria in order to ensure that the claims meet all legal requirements. The home health agency is accountable for the appropriate and timely submission of claims. Inappropriate claims could result in de-certification of the home health agency.
Q10. What should I do to make sure that my patient qualifies for home health care coverage?
A10. It is important for you to obtain adequate assurances from every home health agency to which you refer patients that they have safeguards in place to appropriately screen coverage determinations. Nevertheless, the ultimate responsibility still remains with the physician who has certified and signed the patient's plan of care. Most home health agencies have quality processes in place to monitor the appropriateness of care.
Q11. What should I not do?
A11. The government has provided numerous examples of suspect activities pertaining to physician liability for certifications in the provision of home health services, such as:
1. Advising a patient to limit their normal activity so that the homebound criteria can be met;
2. Certifying a patient's plan of care as a "courtesy" to a patient, or Home Health Agency when you have not first made a determination of medical necessity;
3. Knowingly or recklessly signing a false or misleading certification that causes a false claim to be submitted; and
4. Receiving any financial benefit for signing a patient's plan of care (including free or reduced rent, patient referrals, supplies, equipment, or free labor).
5. Backdating orders to accommodate a home health agency's lack of documentation or untimely submission of claims.
Q12. I heard that the government is planning to change the Medicare definition of the term "homebound." What is the status of this proposed change?
A12. In a recent report issued on April 29, 1999, the Department of Health and Human Services has recommended to Congress that no changes be made to the current definition of "homebound. HHS has concluded that, until additional information is available to more accurately determine home health eligibility, the current definition should remain in place.
Q13. Who should I contact if I have a question?
A13. If you have any questions or would like additional information about this issue, please contact the Office of Compliance at 265-8359. Anyone wishing to remain anonymous may report concerns to the confidential Gator Compliance Hotline at 1-866-574-2867
If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.
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