Need To Know More About Medicare and Home Health Care?

Home health agencies have their deadlines of 2014 rushing at them. If the agency has not been putting all the requirements into place as they were due, that deadline will be chaotic and difficult. This deadline of January 1, 2014 was set in 1999 when Medicare changed all the rules and regulations concerning Home health Care. These changes began January 1, 2000 and cms.gov has them all laid out on their website, under home health care. Every agency at that time had the opportunity to change.  Everyone at that time was given the tools not only to follow Medicare guidelines for their patients, improve the patient’s health and well-being but also to raise the bar on all their home health staff.

It is true that change is never easy; it is doubly true that it is difficult to get everyone in the agency to want the desire to change as well as want to continue that change, to set their own bar of expectations and education higher than they ever had previously. If the agency management did not start in 1999 getting their staff excited about Medicare guidelines, then as the decade continued it would have become even harder to set the changes into motion. If the agency has not embraced the changes by now, then it is unlikely to change at all b this time. At that point, one must wonder at the motives of the agency and its management. The more suspicious of people may well be expecting those types of agencies to be waiting for January of 2013 to use that last year acquiring a buyer for their agency, thus cutting their loses, running with whatever profits they have already set aside.

Navigating the cms.gov website is not difficult but can seem a daunting task when first trying to tackle it. An easier way is to add “The Federal Register” to your list of favorites. This is an online publication that does nothing except keep everyone abreast of all the deadlines and or proposal and or so called ‘new’ changes. Again, it must be emphasized that while many say, “Medicare is always changing the rules and it is hard to keep up with them” this is not exactly true. There have been proposals to the Medicare guidelines and these have subsequently been put into effect or not, depending on the legislation in the District of Columbia.

For example, there have been two changes to the Medicare guidelines starting in January of 2011 and another to affect home health agencies effective January of 2012. The one that was set into motion January of 2011 was a 3.75% decrease for PPS (Prospective Payment System) that Medicare has been paying to all agencies since January of 2000. First, the explanation of PPS is necessary in order to grasp the monetary aspect of this decrease. Home Health Agencies nationwide used to be able to bill Medicare for every visit they did on every Medicare patient.  One of the first changes that occurred was in the way every patient was assessed. This assessment was and still is very similar to the MDS (Minimum Data Set) started in 1989 for all nursing homes. Both are similar to the way hospitals have determined the DRG’s (Diagnosis Related Groups) by which Medicare determines their payment.

In 2010 Medicare began monitoring HHA across the country to see if they had set into place the actions necessary for face-to-face encounters whose deadline was April 1, 2011. Again, it needs to be emphasized that this is not a “new” change to HHA. They were fully informed years in advance. Still, the percentages of compliant HHA were very low. In the summer of 2010 Medicare announced and 3.35% decrease in the PPS monies to be allotted to HHA’s beginning January 2011. The reason for this decrease was also succinctly laid out for the HHA to understand. If they were not compliant with all changes begun a decade ago my Medicare, they would be penalized.

In the year 2011, Medicare continued to monitor HHA across the country and what was found should make every nurse, therapist and manager hang their heads in shame. Medicare found that an increase of upcoding and a decrease in viable documentation that proved they improved the patients overall care and well-being existed! Upcoding means making the patient's diagnosis worse than what it really is. In other words, lying in order to obtain more money for every sixty-day episode. The worst, to this RN’s mind, s not proving on paper that the patient was better when they were discharged! What are we in their homes for; if not to help them get better?

Therefore, on July 12, 2011 Medicare announced its proposal of another decrease in PPS monies. The initial decrease was 4.75% however, this has now come down to 3.79% and it becomes effective January of 2012.

These decreases to the amount of monies that every Home Health Agency could be making if only they were following Medicare guidelines can make one think two things.

1) These types of HHA’s never took Medicare seriously in 1999, much less in 2011.

2)  These HHA’s will be the first to either sell or go bankrupt prior to January of 2014 and run with whatever profit they have managed to glean over what will be at that time thirteen years.

The ones most damaged by these types of agencies, of course patients and their families, staff of the agencies. However, it is the management that should be held totally responsible, as they had the prior knowledge from the start, unless they have been living without the benefit of technology today.

The staff should also shoulder some responsibility for all of them know that “ignorance is no excuse” and they should have had the desire to learn as much as possible about their chosen healthcare field. However, there have also been many staff, from nurse to therapist, who are aware of Medicare guidelines for home health and who may even have had the benefit of working for an agency where it was proven that using Medicare guidelines not only works but is profitable! When these staff try to speak up, many are ostracized, harassed, even fired it may be due to the agency not wanting to shoulder the expense, time or the stress of improving the patients outcome at the eleventh hour.

Hopefully, in 2013, it will be an even greater change in home health agencies than in 1999. Hopefully this time it will not be the small agencies that suffer. Hopefully, this time Medicare will take care of the agencies that have not been compliant with Medicare guidelines for over a decade. Medicare has more of an advantage now, more ability to see what is going on in home health now and the state boards of nursing as well as CHAPS and or JCAHO have been following along much better than previously.
barbara bethard