Agencies slam new Medicare rule on home care

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March 25, 2011
Agencies slam new Medicare rule on home care
By Phil Galewitz | Kaiser Health News

WASHINGTON — 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 next 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.

(Kaiser Health News is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health care policy organization that isn't affiliated with Kaiser Permanente.) ON THE WEB

Read more: http://www.mcclatchydc.com/2011/03/25/111076/agencies-slam-new-medicare-rule.html#ixzz1JEcnzOBG

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"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."

HOW is it that someone gets home health care without seeing a Dr.? the prescription can be written as part of the orders upon leaving the hospital.

Most people get this home health care after being in the hospital. I know family members that have requested home health care for their loved ones, usually elderly parents, and have filled that position for the parent.

But I would hope that the Dr. verified the actual need. If mom or dad needs laundry, bathing, shopping, meal prep., house cleaning, etc done for them, that needs to verified by the Dr. - or at least signed off by the Dr's physician assistant with an office or better yet, an in-home visit.

That's what was done for my 88 year old mother when she was in her own apartment. Her "aide" was paid little for the jobs she did.

Any more info on how this system is being "abused"?
Follow the money trail. That always seems to be the REAL issue.

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@PUNKEY,

First Miami defendant in nation’s biggest health fraud case pleads guilty
BY JAY WEAVER
[email protected]

The first Miami defendant in the nation’s largest mental healthcare fraud case pleaded guilty to paying millions of dollars in kickbacks in exchange for Medicare patients who didn’t need the costly therapy.

Her job as marketing director for a Miami-based mental healthcare chain was to bring in the patients and nobody did their job better than Margarita Acevedo.

Investigators say she paid millions of dollars in kickbacks to South Florida assisted-living facilities, halfway houses and recruiters to supply thousands of Medicare beneficiaries to American Therapeutic Corp.’s chain of seven clinics -- patients who didn’t need the costly treatment.

On Thursday, Acevedo, 41, of Southwest Miami-Dade, pleaded guilty to conspiring to pay kickbacks in exchange for patients and conspiring to bilk between $100 million and $200 million from Medicare, in the largest mental healthcare fraud case in the country.

Her change of plea in a Miami federal court makes Acevedo the first defendant among 24 indicted since last fall to admit playing a role in American Therapeutic’s “massive fraud scheme” against the taxpayer-funded healthcare program for seniors and the disabled, according to court records.

She faces between 12 and 15 years in prison at her mid-July sentencing, according to sentencing guidelines.

Prosecutors are expected to recommend a lesser sentence because she is providing the Justice Department with an insider’s view of the alleged racket.

Her attorney, Ira Loewy, declined to comment Friday on her cooperation with authorities.

Acevedo, who joined American Therapeutic in 2005, admitted in a “factual” statement that “in her role as a manager, she worked with the [company] leaders and organizers in recruiting ALF and halfway house owners and supervised co-conspirators in tracking and paying the kickbacks.”

For their part, the residential operators acted as recruiters who took bribes from American Therapeutic’s clinics - $30 for each patient’s daily visit - for supplying thousands of Medicare beneficiaries to keep the racket rolling, authorities say.

American Therapeutic, founded in 2000, allegedly ran its operation for years, tapping into a stream of mentally ill patients who were supposed to have received treatment in local hospitals before qualifying for outpatient group therapy sessions.

Despite conspicuously high claims, the Medicare program never raised an eyebrow. Things began to unravel years later when clinic employees started complaining that many patients were beyond help because they suffered from dementia or Alzheimer’s disease. One employee was fired, leading to a whistle-blower probe of American Therapeutic that became the foundation of the criminal investigation.

Acevedo’s bosses were Lawrence Duran, 48, of North Miami, and Marianella Valera, 39, of Miami, owners of American Therapeutic. They were charged with directing the conspiracy to defraud the Medicare program, leading a network of company employees, psychiatrists and patient recruiters who also face criminal charges.

In March, the couple’s lawyers told U.S. District Judge James Lawrence King that they plan to plead guilty, but they have not done so yet. Their trial is set for August.

Duran and Valera were poised to change their initial not guilty pleas, but a major dispute over how much the couple allegedly bilked from Medicare held up everything. Their lawyers, Lawrence Metsch and Arthur Tifford, have argued that the figure should be $83 million, the actual amount the federal program paid their company since 2003.

Justice Department attorney Jennifer Saulino has argued that the figure should be about $200 million, the amount their company billed Medicare during that period.

The feds have frozen the couple’s personal and corporate bank accounts, Saulino said. They also possess about $7 million in assets, such as luxury cars, real estate and jewelry, that authorities seized with a temporary restraining order.

. Duran, who was born in New York, and Valera, a native of Peru, are being held at the Federal Detention Center in Miami because a judge found both to be a flight risk.

Read more: http://www.miamiherald.com/2011/04/08/2158019/first-miami-defendant-in-nations.html#ixzz1JEiKhmsh

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The problem with the new Face-t0-Face rules lies less in the requirement for a face-to-face encounter and more in the implementation of the rule. The rule does not simply state that patients must have seen a doctor in a reasonable time frame. That would be okay. Instead, the rule adds a page or more of paperwork that the doctor must fill out in his/her own words stating how the patient meets Medicare's skilled need requirements and how the patient meets Medicare's homebound requirements. Doctors haven't filled out home health plans of care in their own words for as long as I've been in the know about home health. Why? Because the inspectors are so exacting about nomenclature that a doctor who only makes five home health referrals per month could never get the wording right. Home health agencies need to be able to assess the patient in the home environment, write what they found, and then have the treating physician sign off that what is written is right. That's the only way to make the paperwork meet Medicare's litigious standards.

The original article said the only problem with the trial period is that the doctors didn't fill out the paper work correctly - as if that were a trivial problem. THAT IS FAR FROM A TRIVIAL PROBLEM WITH MEDICARE! If the paperwork is not filled out correctly, the home health agency gets their payments taken away - EVEN IF ALL THE MEDICAL CARE WAS DELIVERED CORRECTLY AND IF THE PATIENT REALLY QUALIFIED FOR CARE! The worst part of that is the government will often let a home health agency make some earnest mistake repeatedly for years, and then show up and take back years worth of payments. Now, this new Face-to-face rule says the home health agency can't fill out their own paperwork, the patient's doctor has to. That's a problem.

The author of the article cites the growth of the home health benefit as evidence that is it "out of control" and in need of unfair, draconian cut back measures. While a handful of states have certainly allowed the certification of agencies that have no business being in charge of medical care, the growth of home health care cannot be cited as proof that it is out of control. Not only are Medicare rolls growing signifying a growing need for home health care, the federal government has been pushing access to home health care for years. Home health care delivered correctly saves thousands of dollars for Medicare in each case. If home health care were not available, many of those same patients would need to spend additional weeks in a hospital or rehab facility. The cost of three days in a hospital typically equals the cost of one month in home health care. Furthermore, significant evidence shows how home-based care prevents unnecessary emergency department visits, unnecessary hospitalizations, and other more expensive utilization of the health care system. So no, you can't cite the amount by which home health spending has increased and say that's bad. If Medicare spent that much on home health, how much did they save in in-patient care?

Gary Brazzell ( Edit [Moderator]: Link removed )

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@GaryBrazzell,

That sounds about right. Certainly, what Medicare covers is highly dependent on the proper coding, so Medical Coding has practically become another medical specialty. Of course, insurance companies have always been sensitive about coding too, but I don't believe all systems are the same. This is why most doctors have more nonmedical staff than doctors and certified practicioners.

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Agencies slam new Medicare rule on home care

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