A growingly common misconception in the home health/homecare industry is that Medicare does NOT cover homecare services. Medicare does in fact cover home health and homecare services for patients who qualify. According to recent reports from advocates for seniors and the home care industry, many of the policies intended to combat fraud and reward the highest quality care have been driving some home health agencies to intentionally avoid taking on long-term patients who are afflicted with debilitating conditions where the prognosis for recovery is low. Complicating matters, many of the rule changes that go into effect this month could very well make the problem even worse.
“We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes,” stated attorney Kathleen Holt. As an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm, Kathleen’s group is contemplating formal legal action against the government.
Federal law indeed requires Medicare to pay indefinitely for home health care, without copayments or deductibles so long as a qualified physician has ordered it and patients cannot leave home without difficulty. These patients must demonstrate a need for intermittent nursing, physical therapy, or other forms of skilled care which can only be provided by a trained professional. Contrary to some beliefs, these patients do not need to show improvement to meet the criteria. Qualified patients can also receive a home health aide’s help with dressing, bathing and other common daily activities. Current rules state that the combined services are limited to 35 hours per week.
Medicare first enacted this policy in 2013, in the midst of settling a lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In the aforementioned case, the government concurred that Medicare covers skilled nursing and therapy services. Those services would be inclusive of procedures delivered at home, either to maintain a patient’s abilities or to prevent or slow a patient’s decline. There was also an agreement to inform providers, auditors in particular but others as well, that a patient’s improvement should not be a requirement for continued coverage.
One patient in particular who was interviewed, says some home health care agencies told him Medicare would pay only for rehabilitation, “with the idea of getting you better and then leaving,” he stated. He was also informed by agencies that Medicare would not pay them if his condition didn’t improve. Additionally other agencies the patient spoke with, informed him that Medicare simply did not cover home health care. Medicaid, well known as the federal-state program for low-income adults and families, would have covered this patient, but he was told he did not qualify by Medicaid officials.
Getting Medicare coverage for home health and home care services requires a great deal of persistence, says John Gillespie, whose mother has dealt with five home care agencies since she was diagnosed with ALS in 2014. Gillespi successfully appealed Medicare’s decision denying coverage, and subsequently upon review, Medicare ended up paying for his mother’s visiting nurse as well as speech and physical therapy. “Having a good doctor and people who will help fight for you helps tremendously,” added Gillespie, who lives in the Orlando, Florida area.
When interviewed for comment, Medicare officials refused to acknowledge any access problems for patients. Their representatives stated that a patient can continue to receive Medicare home health services as long as he or she remains eligible for the benefit, official spokesman for Medicare Jonathan Monroe told the press.
One of the problems causing confusion and misinformation, is that some home health agencies fear they won’t be paid if they take on patients who need long term services. Cases that span long periods of time can attract the attention of Medicare auditors, who could deny payments if they believe the patient is no longer eligible, or they suspect the often penalized billing fraud. Rather than run the risk of not getting paid, some home health agencies attempt to stay under the radar by taking on lower numbers of Medicare patients who require long-term care. To some extent, these companies may have good reason to be concerned. Medicare officials found in 2017 that about a third of their payments directly to home health firms in the fiscal year ending last September, were improper.
A national shortage of home health aides in a great number of areas could also be a factor which leads overburdened agencies to focus on short term patients as a rule of thumb. An additional factor that may have a negative effect on chronically ill patients is Medicare’s “Home Health Compare” ratings website. The site includes grades on items such as patient improvement, for instance whether a client got better at walking with an agency’s assistance. That effectively communicates a reward to agencies who want top ratings, to actively seek patients with a high chance of improvement verse those who are declining or chronically ill.
In 2018 some home care agencies will earn more than just ratings under the Medicare site. Under a new pilot program, home health firms in nine states will begin to receive payment bonuses for providing good care. Another new rule, which took effect recently, prohibits agencies from discontinuing services for Medicare and Medicaid patients absent a doctor’s order.
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