Home Health Care and What Medicare

Changes Mean in 2011

Amanda McGauleyNURS 450

Why these changes and why now?

• This statute was implemented to help reduce cases of Medicare fraud through ensuring the physician (or other health care provider) has current knowledge about his/her patient’s present condition rather than basing the need for services on a so-called “blind guess” (American Academy of Nurse Practioners, 2011).

Questions to be Asked• Does the size of the agency greatly impact how

much money is reimbursed/lost on a daily basis?

• Which region of the United States has been affected more by these changes?

• Are there specific services which are reimbursed less?

• What are the most common reasons for failed reimbursement?

• Will these regulations help or hinder the reduction of Medicare fraud?

Implications for Research• As we are well aware, the current state of

the economy continues to be rather volatile. For the month of August, 2011, companies did not hire employees, keeping the national unemployment rate at 9.1% (United States Department of Labor, 2 September 2011)1. Statistics for the state of Michigan are even more dismal, rounding out the month of July, 2011 with 10.9% unemployed (USDOL, 19 August, 2011)2

Implications, Continued• With these factors, it makes it rather

difficult for people to seek out health care. Those who need it, can’t afford it and those who have access to it are more than likely paying higher premiums.

• Because of the lack of seeking out health care as well as Medicare cuts, there is very little revenue being generated for the home health care companies in this nation.

Implications, Continued• Recently, all employees for our home care company

received a letter from our CEO. Within the content of this letter, there is mention of other home health agencies similar in size, having 60,000 fewer home care episodes each month when compared to the same period as 2010. “Doctors feel it is easier to send a patient to a skilled nursing facility than to seek out home care agency assistance” because of the new requirements placed upon them as health care providers (W. Deary, personal communication, August 26, 2011)

• Publicly traded home care agencies have seen up to 75% loss in their market shares thanks in part to these new regulations (Reuters, 4 August, 2011).

Implications, Continued• According to Medicare (2011)2, on July 5, 2011, it

was determined by the Federal register to “update the Medicare Home Health Prospective Payment (HH PPS) rates for CY 2012 by a negative 3.35 percent. This includes an estimated net decrease of $640 million compared to home health payments in CY 2011. This update includes the combined effects of the 1.5 percent market basket and wage index updates (a $310 million increase), as well as reductions to the HH PPS rates to account for increases in aggregate case-mix that are not related to changes in the health status of patients (a $950 million decrease).”

Implications, Continued• Recently as of October 3, 2011, the United States

Senate released a report on the nation’s largest home health care companies and how they essentially used Medicare rules to “game the system.”

• This was done by coercing staff members to add therapy visits to reach the next reimbursement tier in order to generate more revenue for the company, despite this not being within the best interest of the patient (Kaushik, 3 October, 2011).

• Given this damning information, one now has to wonder how effective these changes will be in controlling rising Medicare and health care costs in general.

What are the Medicare Changes for 2011?

• Effective April 1, 2011, the following changes were made regarding Medicare regulations and how home health care agencies across the United States are reimbursed for services rendered:

• All patients admitted to home health services are required to have a face-to-face encounter with either a physician or non-physician provider (i.e.-nurse practioner or physician assistant) within “no more than 90 days” prior to the start of care (SOC) or “no less than 30 days” after the SOC (Centers for Medicare and Medicaid, 2011, p. 17)1. 

What is Face-to-Face?• Face-to-face is a document the

health care provider ordering home care services must complete to justify the reasons home care is ordered rather than having the patient go to an outpatient facility. The home care agency then has to provide care based on the diagnoses the health care provider notes.

What happens if this doesn’t take place?

• Should the face-to-face requirement not be met during the allotted time, the patient has to be discharged off services and readmitted. Not only does this tax staffing issues, it also results in a loss of revenue for the home care agency (HHA). The HHA is more than likely not going to be reimbursed for the services conducted during that time period.

More Changes• For those patients receiving therapy services

(physical, occupational and/or speech), reassessment visits must take place no later than the 13th and 19th visits (The American Occupational Therapy Association, 2011).

• The reassessment visits are conducted by the respective discipline before these allotted time frames as a means to determine if the patient needs further therapy services as well as determine which goals have been met and those which need updated (Skrine & Brown, 2011).

Changes, Continued• Once these reassessment visits have been

completed, a new evaluation period begins.• The key to remember is that should the

reassessment visits fail to take place at the 13th and 19th visits, the “care that is provided after that time will not qualify for Medicare coverage” and the patient could be responsible for any charges accrued (Homehealth Strategic Management, 21 February 2011).

The Omnipresent G-Code• G-codes are essential to the home health

care setting as it is these codes that determines how a skilled visit is billed for reimbursement per 15 minutes of care provided. While the use of the G-code is not new for home care, they have been “updated to include reporting visits conducted by therapy assistants, the use of maintenance therapy programs as well as expanded codes for nursing” (Fazzi Associates, 2011).

G-Codes Continued• For the fiscal year 2011, the following G-

codes have been added:– G0157 and G0158. Essentially these codes

were added to differentiate between the services provided by a therapist versus a therapy assistant, which greatly impacts how the visit conducted is billed and reimbursed (CMS, 2010, p. 3).

– Along the same vein, new G-codes were also implemented for the billing of direct patient care by a skilled nurse. They are as follows:

G-codes, Continued– G0162-skilled services by an RN only for

the management and evaluation of the plan of care and;

– G0163-skilled services by a licensed nurse for the observation and assessment of the patient’s condition (CMS, 2010, p. 6).

As stated previously, the differentiation as to who it is that provides the service greatly influences how the visit is billed and reimbursed.

Theory Bases• Neuman systems model-patients are

viewed as “wholes whose parts are in dynamic interaction; has an open system by which the elements are continuously exchanging information” (Toomey & Alligood, 2006, p. 320).

• Functionalism-human society is a system of interdependent parts which function to benefit the whole and the survival of the society.

Pros for Medicare Changes for Home Health

• We have explored some of the implications for the recent changes regarding how home health care is provided; most of which bear negativity. But is this always the case? More than likely, probably not.

• Medicare (and Medicaid) fraud is a sad reality in this country. For 2010, there was an estimated $97 billion worth of fraudulent claims uncovered. As Medicare spending increases, “so does fraud” (Singer, 2011).

Pros for Change, Continued• As previously stated, these new changes

for home health are to help curb inappropriate use of Medicare dollars and to reduce the rate of fraudulent activities.

• The changes also cut excessive profit sharing margins, reduce the number of for-profit agencies, and look to help eliminate questionable business practices among home health care agencies (Sharp, 2010; Carter, 2011).

Pros for Change, Continued• In regards to the differentiation

among the G-codes, these were implemented to help further distinguish whom is providing care to the homebound patient.

• With this differentiation, costs for providing care are better contained; and can in turn offset increasing rates.

Research• As previously stated, further research

needs to be conducted to assess how efficient or inefficient these changes are when it comes to reimbursement for home health care companies.

• Research also needs to be conducted to assess if the changes impact the reduction of Medicare fraud as hoped when these regulations went into effect.

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“If it’s going to be, its up to me”• Home health clinicians need to be

cognizant and make sure the visits they are doing are indeed skilled and billable

• Therapists need to make sure their reassessment visits are on or before the 13th and 19th visits

• Those completing home health admission visits must educate the patient on the importance of having face-to-face completed in the allotted time frame

References• American Academy of Nurse Practioners. (2011). Medicare home health face-

to-face encounter requirement enforcement begins April 1st. Retrieved from: http://www.aanp.org/AANPCMS2/LegislationPractice/FederalLegislation/Medicare/Medicare+Home+Health+Face+To+Face+Encounter+Requirement++Enforcement++Begins+April+1.htm

• American Occupational Therapy Association, The. (2011). AOTA analysis: final home health PPS rule. Retrieved from: http://www.aota.org/News/AdvocacyNews/Final-2011-Home-Health-Rule.aspx

• Carter, A. (2011). Home health clinicians play a vital role educating policymakers. Home Healthcare Nurse, 29, (1): 55-56.

• Centers for Medicare and Medicaid. (2010). CMS manual system. Pub 100-02, one time notification, transmittal 824. Retrieved from: https://www.cms.gov/transmittals/downloads/R824OTN.pdf

• Centers for Medicare and Medicaid. (2011)1. CMS manual system. Pub 100-02, Medicare benefit policy, transmittal 139. Retrieved from: https://www.cms.gov/transmittals/downloads/R139BP.pdf

References, Continued• Centers for Medicare and Medicaid. (2011)2. Home health prospective payment

system regulations and notices. Retrieved from: https://www.cms.gov/HomeHealthPPS/HHPPSRN/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=3&sortOrder=ascending&itemID=CMS1249242&intNumPerPage=10

• Fazzi Associates. (2011). 2011 G-code guidelines. Retrieved from: http://www.fazzi.com/BE_2011-g-code-guidance.html

• Homehealth Strategic Management. (21, February 2011). Part Three-final rule: therapy requirements and how to address changes. Retrieved from: http://www.homehealthstrategicmanagement.com/Articles/tabid/1520/articleType/ArticleView/articleId/1123/Part-Three--2011-Final-Rule-Therapy-Requirements-and-How-to-Address-Changes.aspx

• Kaushik, K. (3 October, 2011). Senate finds home health care companies at fault. Retrieved from: http://www.reuters.com/article/2011/10/03/us-home-healthcare-idUSTRE79268220111003

• Reuters. (4 August, 2011). Update 3-Gentiva lowers outlook as reimbursement hits hard. Retrieved from: http://www.reuters.com/article/2011/08/04/gentiva-idUKL3E7J43B420110804

References, Continued• Sharp, M. (14 December, 2010). Medicare home health changes for 2011 &

beyond. Retrieved from: http://www.healthcarereforminsights.com/2010/12/14/medicare-home-health-changes-for-2011-beyond/

• Singer, B. (2011). Medicare fraud strike force: 2010 and beyond. Retrieved from: http://www.hcca-info.org/regional/2011/Orlando/Singercolor.pdf

• Skrine, R. & Brown, J. (2011). Home care rule will take effect on April 1. Retrieved from: http://www.asha.org/Publications/leader/2011/110315/Home-Care-Rule-Will-Take-Effect-on-April-1

• Toomey, A. & Alligood, M. (2006). Nursing theorists and their work, 6th ed. Stl Louis, MO: Mosby Elsevier.

• United States Department of Labor. (2 September 2011)1. Employment situation summary. Retrieved from: http://www.bls.gov/news.release/empsit.nr0.htm

• United States Department of Labor. (19 August, 2011)2. Regional and state employment and unemployment summary. Retrieved from: http://www.bls.gov/news.release/laus.nr0.htm