Medicare Certified Home Health Agency “Under Arrangements” With “In Home Care” Agencies Or Organizations

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THIS ARTICLE IS INTENDED TO SUPPORT THE READER’S AWARENESS AND UNDERSTANDING.  IT IS NOT LEGAL ADVICE.   IF THE READER SEEKS LEGAL ADVICE CONCERNING HIS OR HER PARTICULAR SITUATION, HE OR SHE SHOULD SEEK OUT AN ATTORNEY IN A LAWYER CLIENT RELATIONSHIP.

 

In order to provide Medicare covered home health services to patients that a Medicare certified home health agency (HHA) does not provide directly,  the HHA may have arrangements with another “in home care” agency or organization , even though that agency or organization is not a Medicare qualified provider of services that is participating in the Medicare health insurance program .

A Medicare certified home health agency (HHA) may have arrangements with another agency or organization in order to provide home health services to patients that the HHA does not provide directly, even though the other agency or organization is not a Medicare qualified provider of services that is participating in the Medicare health insurance program .  See Medicare General Information, Eligibility and Entitlement Manual CMS Pub. 100-01, Ch. 5, § 50.2 (A)(B)(C).

These are arrangements under which receipt of payment by the HHA for the services discharges the liability of the patient or any other person to pay for the services. Whether the items and services are provided by the HHA itself or by another agency under arrangement, both must agree not to charge the patient for covered items and services and must also agree to return money incorrectly collected. See Medicare General Information, Eligibility and Entitlement Manual CMS Pub. 100-01, Ch. 5, § 50.2 (A).

In permitting HHAs to furnish services under such arrangements, the HHA is not to merely serve as a billing mechanism for the other party or agency under arrangement  . For services provided under arrangements to be covered, the HHA must exercise professional responsibility over the arranged-for services and ensure compliance with the home health conditions of participation. See Medicare General Information, Eligibility and Entitlement Manual CMS Pub. 100-01, Ch. 5, § 50.2 (A).

The HHA’s professional supervision over arranged-for services requires application of many of the same quality controls as are applied to services furnished by the HHA’s salaried employees. The agency must accept the patient for treatment in accordance with its administration policies, maintain a complete and timely clinical record of the patient that includes diagnosis, medical history, physician’s orders, and progress notes relating to all services received; maintain liaison with the attending physician with regard to the progress of the patient and to assure that the required plan of treatment is periodically reviewed by the physician; secure from the physician the required certifications and recertifications; and ensure that the medical necessity of such services is reviewed on a sample basis by the agency’s staff or an outside review group. See Medicare General Information, Eligibility and Entitlement Manual CMS Pub. 100-01, Ch. 5, § 50.2 (A).

If the arrangement is made between the HHA and another provider participating in the health insurance program (hospital, skilled nursing facility, or HHA, and, in the case of physical therapy, occupational therapy, or speech-language pathology services, clinics, rehabilitation agencies, and public health agencies), there must be a written statement regarding the services to be provided and the financial arrangements. See Medicare General Information, Eligibility and Entitlement Manual CMS Pub. 100-01, Ch. 5, § 50.2 (B)

If the arrangements are is made between the HHA and an agency or organization that is not a qualified provider of services and therefore is not a provider participating in the Medicare health insurance program , there must be a written contract between the HHA and that agency or organization that includes all of the following:

  1. A description of the services to be provided.
  2. The duration of the agreement and how frequently it is to be reviewed.
  3. A description of how personnel will be supervised.
  4. A statement that the contracting organization will provide services in accordance with the plan of care established by the patient’s physician in conjunction with the HHA’s staff.
  5. A description of the contracting organization’s standards for personnel, including qualifications, functions, supervision, and in service training.
  6. A description of the method of determining reasonable costs and reimbursement by the HHA for the specific services to be provided by the contracting organization.
  7. An assurance that the contracting organization will comply with title VI of the Civil Rights Act.   See Medicare General Information, Eligibility and Entitlement Manual CMS Pub. 100-01, Ch. 5, § 50.2 (C)