“I contract with multiple home health agencies in my city and the surrounding suburbs. A constant topic of discussion is the competition between agencies for patients. There always seems to be friction between agencies regarding what provider an individual client might use and how that decision is made. Can you comment on how the CMS regulations address this issue?”
When CMS initially installed the Prospective Payment System (PPS) as a reimbursement and programming model for Medicare certified home health, a decided emphasis was placed on corporate compliance issues as a means of reducing fraud and abuse in the industry. Office of Inspector General findings from the mid-1990’s had revealed alarming levels of service delivery and other practices that compromised the Medicare home health benefit and the financial future of the program. Corporate compliance regulations were introduced and it became the responsibility of participating home health agencies to implement and monitor behavior of staff in these areas. Corporate compliance monitors, hotlines and educational programs were required of all home health providers. However, many agencies at that time failed to grasp the intent of these regulations while distracted by the rigors of the PPS installation and subsequent staff education they were managing. Some providers continue to struggle with corporate compliance guidelines in today’s homecare arena. Further complicating the matter is the constant staff turnover and the difficulties in adequately orienting employees new to home health regarding the importance of these issues. Your question revolves around patient choice and the role it plays in the home health environment.
To adequately understand how CMS views the concept of patient choice, it is important to define the Medicare benefit and the distribution of services. All Medicare enrollees have access to federally managed Medicare based services if they meet the participation requirements. It is important to note that Medicare certified home health is just a single example of a pre-paid benefit that has been funded by payroll deductions of the working public. Current enrollees have effectively self-funded their care by contributions in the form of these payroll deductions from the wages of themselves or their family members. As a federal benefit program monitored by the Department of Justice, it is fair to compare the integrity of the home health program to that of the US Postal Service.
As we stated earlier, a central theme of CMS’ corporate compliance program is patient choice. It is easy for agencies to temporarily lose focus in this area as competition between agencies for patient caseloads continues. Many providers employ marketers to communicate with referral sources as to the benefits provided by their agency. This practice in itself is not problematic, but it can often lead to undesirable scenarios that compromise compliance principles. Doctors or nurses that lack understanding of patient choice laws begin to view the direction of a home health referral as their call. This situation is evident when acute care discharges from a health system that has a homecare agency are automatically referred to the affiliated agency. MD’s, nurses, social workers and other discharge personnel are often unaware that a patient has freedom of choice as to the Medicare provider they choose to provide a home health program. It is no more appropriate for a physician to have an opinion regarding what agency to refer a patient to than it is for him to direct a patient to a specific pharmacy for prescription refills. This situation often leads to gross misinterpretations in all directions: commonly heard is the practice of discharge personnel handing patients prepared lists of certified home health agencies in the area to avoid any conversation that may be misconstrued as influencing patient choice.
Also common is the practice of agencies marketing living facilities to provide home health services to the residents. Again, this practice by itself defines no inherent compromise of patient choice. Living facilities may provide suggestions or even recommendations of specific home health agencies as long as the final decision remains with the patient. The desired scenario has various residents of a specific facility receiving services from a group of agencies that each patient has chosen individually. Problems arise when agreements between home health agencies and the living facilities result in the coercion of patients or families to use a specific provider. This is a corporate compliance violation of the highest order.
Also extremely troubling are agencies that seem to function in either ignorance or violation of patient choice regulations. Particularly reprehensible is the practice of requesting physicians to write orders naming the specific agency as the provider of the Medicare service. This practice is successful in large part due to the lack of knowledge of Medicare laws by the referring physician or their staff. Again, this is a corporate compliance violation of the highest order.
In order to remain in compliance with the Medicare regulations regarding patient choice, it is important to turn to the patient or their representative and encourage them to make an independent decision as to the desired provider. When any dispute arises regarding choice of agencies, the patient (not the physician) ALWAYS makes the final decision.
[Concerns regarding corporate compliance violations (including patient choice) can be reported at 1-800 HHS-TIPS].
Teri N. Thompson and Arnie Cisneros are physical therapists with nearly 40 years of combined home care experience. Co-owners of Home Health Strategic Management in East Lansing, MI, they provide clinical service management and home care consulting expertise. They are nationally renowned speakers regarding the PPS refinements of 2008 and therapy utilization under the New Rule.