Physiatry Practice Management Resources

Yet only about 10 to 25 percent of physicians are charging to certify or recertify someone for home care, says internist Peter A. Boling, professor of medicine at Virginia Commonwealth University School of Medicine in Richmond, VA. "Most doctors don't understand the billing options," notes Boling, who's also a former president of the American Academy of Home Care Physicians. He rejects the arguments of some physicians that the paperwork is too burdensome. Kagan agrees that it's no big deal, once staffers learn how to do it.

However, interviews with several physicians suggest (and an HHS Office of Inspector General report confirms) that many doctors are afraid of being audited if they fail to conform to the tricky Medicare rules on home care. If they don't bill for certification, they believe, they're lowering their risk.

Internist Mary Ann Bauman of Oklahoma City acknowledges that her practice doesn't bill for certification partly because "it makes us nervous to do any of the more unusual stuff with Medicare. I don't want to bill for anything unless I absolutely know what the rules are and know that I'm following them properly."

If you, too, are leaving money on the table because you're afraid of violating Medicare regulations, read on. There's less to fear than you think; and if you follow the rules, you could be earning more and providing better care for your patients.

The fear factor is overrated

In 1999, the Office of Inspector General published a "special fraud alert" on home healthcare that made many doctors leery of this area. The OIG warned that "physician laxity in reviewing and completing [home health] certifications" was facilitating fraud and abuse in the industry. It also warned doctors that they could be liable for criminal and civil penalties if they failed to determine the medical necessity of home care. But the alert also said they wouldn't be punished for mistakes or "simple negligence." And in its report three years later, the OIG emphasized that doctors can be held liable only if they "knowingly sign false or misleading certifications."

There have been a few well-publicized prosecutions of doctors in connection with home care fraud. For example, in 2002, a federal court in Missouri found FP Jan Dierks Garwood guilty of conspiracy to defraud Medicare. The suit charged that he accepted kickbacks in exchange for home health referrals and falsely certified that patients were homebound. But healthcare attorneys say the government hasn't taken legal action against physicians for making honest mistakes in home care certification or care plan oversight.

David M. Glaser, a Minneapolis attorney who specializes in Medicare audits, notes that the doctors who should pay the closest attention to the regulations are those who have a financial relationship with an agency. The Stark rules allow you to refer patients to an agency that employs you as a medical director, he points out, but financial ties with a home care firm may create problems if questions ever arise about your referrals.

If a physician submits home health claims "recklessly" on a regular basis without doing any supervision, he could face penalties, says Lester J. Perling, an attorney with Broad and Cassel in Fort Lauderdale. "But if a doctor occasionally orders home healthcare, and once in a while he's loose or sloppy with the criteria, that's not going to get him in trouble." The worst that could happen, he says, is that he might have to return some Medicare payments.

Home health agencies, adds Perling, will usually let a physician know if he's ordering home care that doesn't conform to the rules. "If they evaluate the patient and he doesn't meet the criteria, they'll tell the doctor that, so they won't have to refund the money to Medicare."

Home health rules in a nutshell

Medicare will pay for home healthcare if it's medically necessary; if the patient is homebound; if the patient is under the care of a physician who has established a plan of care; and if the patient needs intermittent skilled nursing care, physical therapy, speech therapy, or a continuation of occupational therapy. There are no specific limits on the number of visits or the length of coverage. However, a patient must be recertified for home care every 60 days.

Many physicians believe that a patient must be bedridden to qualify for home health coverage, notes William Restum, CEO of Health Care Partners, an agency in Southfield, MI. But that's not what "homebound" means. According to CMS, "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."

A patient who's considered homebound may go to a doctor's office, a dialysis center, or an outpatient cancer treatment facility. Occasional outings to attend church services, go to the barber, or attend a family reunion would also not disqualify a patient from receiving home care. So the definition doesn't preclude patients from leaving their home; it just must be difficult for them to go out.

CMS lists a number of things it expects to see in a plan of care for a home health patient. (For details, see "Medicare Benefit Policy Manual, Chapter 7—Home Health Services," www.pmandr.com/downloads/pdf/Medicare Benefit Policy Manual.pdf) Home care agencies will usually "flesh out" your instructions to include all of these elements in the care plan they send you. However, remember that you are responsible for reviewing the plan and making sure the medications included in it are correct.

Seeing the patient is not mandatory

Physicians usually want to see patients before they certify them for home care, says Cheryl Lamade, executive director of Cambridge Home Health Care, based in Medina, OH. But the Medicare home health regulations don't actually require it. "It is expected, but not required for coverage, that the physician who signs the plan of care will see the patient," says the CMS policy manual.

In many cases, Restum notes, patients are referred to home care agencies as part of hospital discharge planning. If the patient's personal physician attends her in the hospital, he can sign the certificate and follow up with the patient later. If a hospitalist is following the patient, Restum points out, that physician can certify the need for home care; but the discharge planner should tell the patient to follow up with her primary care physician in a week or two and should also let that doctor know that she's receiving home care.

While it's not easy for debilitated patients to come to your office for certification, most of them can get there with the aid of family members, notes med-peds specialist Salvatore S. Volpe of Staten Island, NY. He wants to see them before recertification, as well, with one exception: If they're recovering from a procedure such as a hip operation, he'll rely on reports from the home care nurses.

A minority of doctors, including Volpe and Kagan, make house calls to patients who can't leave home without an ambulance. If an office-based doctor can't or won't visit a patient, or the person doesn't have a regular physician, some agencies will use a specialized home care physician to check on the patient for home health certification. While there are only a few thousand such doctors in the country, their ranks are growing.