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AN ACTIVELY PARTICIPATING PRIMARY CARE PHYSICIAN AND THE ” DEMAND BILLING” PROCEDURE ARE TWO VERY IMPORTANT KEYS TO THE DEVELOPMENT AND ESTABLISHMENT OF A CUSTOMIZED AND COMPREHENSIVE HOME HEALTH CARE PLAN FOR THE MEDICARE BENEFICIARY .

A. To obtain Medicare Home Health Care Services, home health care must follow a written plan of care that is established and periodically reviewed by a doctor of medicine osteopathy or podiatric medicine.

Although such plan is established and periodically reviewed by such attending physician, it is established and reviewed by the doctor in consultation with the Medicare Certified Home Health Agency staff. The plan of care must be specific and comprehensive, covering all pertinent diagnosis . It is to be reviewed by the attending physician and HHA personnel at least every 60 days. There is no requirement that the certification be entered on any specific form or handled in any specific way as long as the approach adopted by the Medicare certified HHA permits the intermediary to determine that the physician certification requirement is met. Patients are accepted for treatment on basis of a reasonable expectation that the patient’s medical nursing and social needs can be met adequately by the home health agency (HHA) in the patient’s place of residence. Care follows a written plan of care that is established and periodically reviewed by a doctor of medicine osteopathy or podiatric medicine. The plan of care established by the attending physician in consultation with the agency covers all pertinent diagnoses- including mental status, types of services and equipment required, frequency of visits, prognosis, rehab potential, functional limitations activities permitted nutritional requirements medications and treatments ,any safety measures to protect against injury instructions for timely discharge or referral , and any other appropriate items . The total plan of care is reviewed by the attending physician and the HHA personnel as often as the severity of the patient’s condition requires , but at least every 60 days or more frequently when there is a beneficiary elected transfer; a significant change in condition resulting in a change in the case-mix assignment; or a discharge and return to the same HHA during the 60-day episode. Agency professional staffs promptly alert the physician to any changes that suggest the need to alter the plan of care. see 42 CFR § 484.18 (a)(b)

The HHA must be acting upon a physician plan of care that meets the requirements of this section for HHA services to be covered.
The plan of care must contain all pertinent diagnoses, including:
The patient’s mental status;
The types of services, supplies, and equipment required;
The frequency of the visits to be made;
Prognosis;
Rehabilitation potential;
Functional limitations;
Activities permitted;
Nutritional requirements;
All medications and treatments;
Safety measures to protect against injury;
Instructions for timely discharge or referral; and
Any additional items the HHA or physician choose to include.
If the plan of care includes a course of treatment for therapy services:
The course of therapy treatment must be established by the physician after any needed consultation with the qualified therapist;
The plan must include measurable therapy treatment goals which pertain directly to the patient’s illness or injury, and the patient’s resultant impairments;
The plan must include the expected duration of therapy services; and
The plan must describe a course of treatment which is consistent with the qualified therapist’s assessment of the patient’s function.
See Medicare Benefit Policy Manual , Ch.7 Home Health Services Section 30.2.1 – Content of the Plan of Care (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

A physician must certify that the medical and other health services covered by medical insurance, which were provided by (or under arrangements made by) the HHA, were medically required. This certification needs to be made only once where the patient may require over a period of time the furnishing of the same item or service related to one diagnosis. There is no requirement that the certification be entered on any specific form or handled in any specific way as long as the approach adopted by the HHA permits the intermediary to determine that the certification requirement is, in fact, met. A written physician’s order designating the services required would also be an acceptable certification. 100 – Physician Certification for Medical and Other Health Services Furnished by Home Health Agency (HHA) (Rev. 1, 10-01-03) A3-3128, HHA-224

B. Although there must be a patient specific, comprehensive assessment that incorporates the HHA’s use of OASIS as a computerized assessment tool, there must also be an assessment of the patient based on objective clinical evidence regarding the patient’s individual need for care .

Therefore denial of home health services by an HHA or the Medicare Contractor ( i.e. . fiscal intermediary) based on numerical utilization screens , diagnostic screens , diagnosis or specific treatment norms , a reviewer’s general inferences or OASIS alone is not appropriate . Each patient must receive, and an HHA must provide, a patient specific, comprehensive assessment that accurately reflects the patient’s current health status and includes information that may be used to demonstrate the patient’s progress toward achievement of desired outcomes The comprehensive assessment must identify the patients continuing need for home care and meet the patient’s medical nursing rehabilitative, social and discharge planning needs. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. The comprehensive assessment must also incorporate the use of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of OASIS items, as specified by the secretary. 42 CFR § 484.55.

The intermediary’s decision on whether care is reasonable and necessary is based on information reflected in the home health plan of care, the OASIS as required by 42 CFR 484.55 or a medical record of the individual patient. Medicare does not deny coverage solely on the basis of the reviewer’s general inferences about patients with similar diagnoses or on data related to utilization generally, but bases it upon objective clinical evidence regarding the patient’s individual need for care. See Medicare Benefit Policy Manual , Ch.7 Home Health Services Section 20.1.2 – Determination of Coverage (Rev. 1, 10-01-03) A3-3113.1.B, HHA-203.1.B)

Medicare recognizes that determinations of whether home health services are reasonable and necessary must be based on an assessment of each beneficiary’s individual care needs. Therefore, denial of services based on numerical utilization screens, diagnostic screens, diagnosis or specific treatment norms is not appropriate. See Medicare Benefit Policy Manual, Ch.7 Home Health Services Section 20.3 – Use of Utilization Screens and “Rules of Thumb” (Rev. 1, 10-01-03) A3-3116.3, HHA-203.3

C. Prior to initially certifying the home health patient’s eligibility, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient .

The physician must certify that:
1. The home health services are or were needed because the patient is or was confined to the home as defined in §20.1;
2. The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech-language pathology services ceased. Where a patient’s sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in §40.1.2.2), the physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification, or as a signed addendum to the certification and recertification;
3. A plan of care has been established and is periodically reviewed by a physician;
4. The services are or were furnished while the patient is or was under the care of a physician;
5. For episodes with starts of care beginning January 1, 2011 and later, prior to initially certifying the home health patient’s eligibility, the certifying physician must document that he or she, or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient as described in §30.5.1.1. The encounter and documentation are a condition of payment. The initial certification is incomplete without them. See Medicare Benefit Policy Manual , Ch.7 Home Health Services Section 30.5.1 – Content of the Physician Certification (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

D. An HHA must advise the patient in advance of the care disciplines and frequency of the visits proposed to be furnished by the HHA, as well the extent to which payment is to be expected from Medicare , both orally and in a written Home Health Advance Beneficiary Notice (i.e. HHABN).

In situations where services are called for under a physician’s plan of care, but the HHA believes the services do not meet Medicare criteria for home health service coverage, the “demand billing” procedure should be used by the beneficiary to request payment for the physician’s plan of care while the plan is being followed by the HHA . HHA’s are required to bill Medicare for the disputed services upon the request of the beneficiary. If, after its review, the Medicare contractor decides that all or some of the disputed services on the “demand bill” are covered and pays for them, the HHA would refund the previously collected funds for these services. The HHA must advise the patient in advance , of the disciplines ( skilled nursing, physical therapy, home health aide etc ) , and the frequency of the visits proposed to be furnished . See Conditions of Participation Patient Rights 42 CFR 484.10 c (i).

In addition , HHA’s are responsible for advising the patient , in advance, about the extent to which payment is expected from Medicare or other sources, including the patient , both orally and in writing , See Conditions of Participation, Patient Liability For Payment 42 CFR 484.10(e)..

In situations where disputed services are called for under a physician’s plan of care, but the HHA believes the services do not meet Medicare criteria for home health service coverage, the demand billing procedure should be used to enforce and execute the physician’s plan of care . Demand billing is a procedure through which Medicare beneficiaries can request Medicare payment for services that : 1) their HHA’s advised them were not medically reasonable and necessary or 2) they failed to meet the homebound, intermittent, or noncustodial care requirements , and therefore would not be reimbursed if billed. The HHA must inform the beneficiary of their decision with a Home Health Advance Beneficiary Notice (HHABN) , which also must be signed by the beneficiary or appropriate representative before any services are provided. Beneficiaries pay out of pocket or third party payers cover the services in question, but HHAs, in return , upon request of the beneficiary, are required to bill Medicare for the disputed services. If, after its review, the Medicare contractor decides that all or some of the disputed services on the “demand bill” are covered and pays for them, the HHA would refund the previously collected funds for these services . See Medicare Claims Processing Manual (Pub. 100-04, Ch. 10, § 50) (Rev 2374 Issued 12-22-11 Effective 3-22-12 Implementation 3-22-12)

E. As the HHABN is only an advisory notice from the HHA that Medicare may not pay the claim, it is not even an initial determination of Medicare as to whether payment will be concerning the physician’s plan of care.

Therefore , it is the initial MSN notice from the Medicare Contractor (i.e. fiscal intermediary) that reviews the claim, not the HHABN notice from HHA providers, which is the actual initial coverage determination by Medicare. Accordingly, it is the initial coverage determination from the Medicare Contractor , not the HHABN from the HHA, which would form the basis of any appeal by the beneficiary .

For all Part A home health care claims , the first notice Medicare beneficiaries should receive informing them that care will not be covered by Medicare is an advisory notice from the HHA via the HHABN. However , the “Medical Summary Notice” ( MSN ) by the Medical Contractor ( fiscal intermediary) that reviews the claim constitutes the real “initial determination” or written notice that that briefly explains what Medicare will pay on the claim . Therefore , it is the initial MSN notice from the Medicare Contractor that reviews the claim, not the HHABN notices from HHA providers, which are the initial coverage determinations that form the basis of an appeal . See 42 CFR § 405.904 (2) Medicare initial determinations, redeterminations and appeals: General description. Claim Appeals

Therefore, an actively participating primary care physician and the “demand billing” procedure are two very important keys to the successful development and establishment of a customized and comprehensive home health care plan for the Medicare beneficiary .

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