The Reform in Home Health Care

In order to understand the prospective payment system (PPS) for home health agencies (HHA), CMS has put together some easily accessible and useful information, which can be found directly on their website.

Outlier claims are inconsistent throughout the country, with some areas having suspiciously much higher percentages than others. The new 10% cap outlier policy was created to regulate the billing activities that may be in conjunction with the integrity issues that take place within the activities of certain home health agencies.

Though CMS has taken into consideration the needs of those patients who fall into the outlier category, such as those who are diabetic and are insulin dependent, those with CHF, and those who need wound care, there are still concerns as to the determination of the outlier policy’s 10% cap being based on the number of outlier payments in the urban areas compared to the suburban areas. For instance, Los Angeles County in California, one of the concerned cities targeted by CMS, consists of approximately 10 million people. Of this population, approximately 10.5% consists of individuals who are at least 65 years old and over. With such a high population, other factors must also be considered, such as the diversity in all groups, the number of patients who live alone, and various other factors. When compared to other agencies in less populated areas that have outlier dollars below 10 percent of their total payments and are assumed not to be affected by the new outlier policy, the comparison appears to be unfairly considered. More services provided as a result of highly populated areas usually mean that more outlier claims will be billed.

It is no question that fraudulent activity in all areas must be regulated. However, it is also a known fact that organizations, corporations, companies, and individuals are driven through incentives. When a home health agency has to wait 60 days to be paid for services provided, it suffers, along with those who are directly providing the services. Home health has been proven to improve and minimize Medicare costs through the decreased number of hospital visits as a result of services provided by home health professionals. With insufficient amounts of available funds to compensate home health service providers, how are agencies expected to survive?

With Love and Luck,

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Understanding Your Medicare Home Health Care Benefits

For many caregivers and families who are searching to find out more information on how they can care for their elders and loved ones, it can seem like a daunting task. One of the most important distinctions that have to be made on your information gathering quest is to know the difference between Medicare covered Home Care vs. all other forms of home care. In this article, we will explain what Medicare Home Care is and how to find out if you or your loved one qualifies.What is Medicare Home Health Care?

Home Health Care is skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury.

One of the services offered to senior citizens by Medicare is Home Health Services. Medicare recipients must qualify for services, and they must be recommended by the individual’s primary care physician or specialty care physician.

Medicare beneficiaries who feel they may need Medicare home care should always look into whether they can actually qualify for Medicare home health services. It is not a general personal care or chore-worker service. Rather, Medicare home care covers limited, specifically defined at-home care related to diagnosed medical conditions, and sometimes includes personal care services.

These Medicare home care services must be prescribed by a physician, and provided through a licensed home health agency. The beneficiary must have a medical condition, or combination of conditions, that require periodic services from a skilled nurse or therapist. A plan of care will be developed that describes the specific services covered. Eligibility and coverage are evaluated strictly so the beneficiary’s conditions and care needs must be aired fully.

Medicare Home Care Qualifications

It is common for an elderly person to need assistance upon discharge from a hospital or in-patient rehabilitation stay. That individual’s physician, sometimes in concert with family members and the patient him/herself, would determine the in-home health care need and complete paperwork that refers the patient to home health care.

Other common situations include the slow physical decline elderly people experience; when that decline includes inability to care for oneself on a daily basis-but nursing home care is not yet required-the physician may recommend home health care for just those tasks the senior is unable to perform.

These four conditions must be met before homecare services can be prescribed and covered by Medicare:

1. Your doctor must decide that you need medical care in your home, and make a plan for your care at home; and

2. You must need at least one of the following: intermittent (and not full time) skilled nursing care, or physical therapy or speech-language pathology services or continue to need occupational therapy; and

3. You must be home bound or normally unable to leave home & leaving home takes a considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons; and

4. The home health agency caring for you must be approved (“certified”) by the Medicare program.

You can always find more information about your benefits and rights at Medicare’s website.

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