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Audio (MP3) Listen in New Window Presentation (PDF) Open in new window Handout (PDF) Open in New Window Medicare Certified Home Health and Medicaid Waiver Services Presented by Regina Loncaric Overview - Medicare Home Health Services • Qualification for Services • Reimbursement - Medicaid Home Health Services • Qualification for Services • Reimbursement - Medicaid Waivers • Family Support Waiver • Community Integration and Habilitation - Medicare Home Health Start Up Home Health Care - Home Health is a way for patients to get the medical care they need while remaining in the comfort and familiarity of their own home. Criteria to Qualify for Medicare Home Health Services To qualify for Medicare home health services, a patient must: - Have a homebound status - Be under the care of a physician - Receive services under a POC established and periodically reviewed by a physician - In need of skilled care on an intermittent basis Homebound Status A patient must meet one of the two requirements to be considered homebound: - Leaving the home is medically contraindicated - Physical assistance is needed to leave the home If the patients meets one of the above they must also meet the following two requirements: - There must be a normal inability to leave the home - Leaving the must require a considerable and taxing effort OASIS - Must identify the patients continuing need for home care and meet medical and nursing needs - Describes the patient’s condition and PT, OT, and SLP service needs - Determine whether an episode is early (first or second) or later (third or later) in the sequence of home health episodes Case-Mix Methodology - Payment rates based on patient characteristics (diagnosis, clinical factors, service needs, etc.) - 60-day episode rates are adjusted by case- mix based on data elements from OASIS (Outcome and Assessment Information Set) Medicare Reimbursement 2012 MCR base rate/episode = $2,192.07 SWA MCR reimbursement/episode = 2,918.59 2013 average rate/episode = 2,137.73 Reimbursement - 60-day episode of care - A split percentage payment is made for most episode periods • Request for Anticipated Payment (RAP) for the first episode may be requested after the first billable visit. 60% of the episode payment may be received. • Final payment of 40% may be requested after all services are rendered and orders received. Plan of Care Requirements - Must contain all pertinent diagnoses, patients ability, medications, and other health and medical needs - Types of services needed and frequency - Must be reviewed and signed by the physician who established the plan of care, in consultation with HHA professional personnel, at least every 60 days - Each review of a patient's plan of care must contain the signature of the physician and the date of review Recertification - Medicare does not limit the number of continuous episode re-certifications for eligible patients - Request for Anticipated Payment(RAP) of 50% of the episode payment may be requested Criteria to Qualify for Medicaid Home Health Services - Patient must be a Medicaid consumer - Provider must be a Medicare Certified Home Health Agency (MCRHHA) - Certification of Medical Necessity may only be done by the qualifying treating physician with the plan of care - Certification requires a face-to-face encounter and appropriate documentation - No homebound requirement Service Locations - Consumer’s place of residence - Licensed child day care center - Early intervention services (EI) for a child 3 years or younger Types of Services Services must be medically necessary as ordered by the treating physician: - Skilled Nursing (Nursing Services) - Home Health Aide (Nursing Services) - Physical Therapy - Occupational Therapy - Speech Language Pathology Services cannot be provided for the purposes of respite or habilitative care Nursing Services Skilled Nursing(SN): - Registered nurse (RN) or a licensed practical nurse (LPN) at the direction of a RN - Care provided within the nurses scope of practice - Care provided and documented according to plan of care - Care must be medically necessary - Care not solely for the supervision of the home health aide Home Health Aide (HHA): - State testing nursing assistant or 75 hour home health aide training program - Provide care within HHAs scope of practice - Services must be medically necessary: • HHA care is necessary to facilitate the nurse or therapist in the care of the consumer’s illness or injury or • HHA to assist the consumer maintain a certain level of health in order to remain in the home setting - Services provided and documented according to plan of care HHA must provide assistance with activities of daily living (ADLs): - Personal care services - Routine catheter/colostomy care - Assistance with routine maintenance exercises and passive ROM activities in support of skilled therapy goals. - Routine care of prosthetic and orthotic devices HHA may provide incidental services such as light chores, laundry, light house cleaning, meal prep and taking out trash after ADLs are met - Main purpose of a home health aide visit cannot be solely to provide incidental services - Incidental services are to be performed only for the consumer HHAs may NOT provide medication administration Therapy Services Therapy services must be reasonable and necessary for the treatment of the patients illness or injury. Therapy services must be: - Inherently complex, can only be preformed by or under the supervision of a skilled therapist - Consistent with the nature and severity of the illness or injury and the patients medical needs - Considered to be specific, safe, and effective treatment for the patients condition Medicare Home Health Rates Home health rates for SFY 2013, effective July 1, 2012, through June 30, 2013 Cost/procedure code: Overhead Billing Unit: One unit per recipient per day SFY 2013 95% of median: $35.62 Less 5%: ($1.79) SFY 2013 rate: $34.03 Cost/procedure code: Registered Nurse (RN) - 99600 TD Billing Unit: Hourly SFY 2013 95% of median: $42.82 Less 5%: $2.14 SFY 2013 rate: $40.68 Cost/procedure code: Licensed Practical Nurse (LPN) - 99600 TE Billing Unit: Hourly SFY 2013 95% of median: $28.32 Less 5%: $1.42 SFY 2013 rate: $26.90 Cost/procedure code: Home Health Aide - 99600 Billing Unit: Hourly SFY 2013 95% of median: $20.71 Less 5%: $1.04 SFY 2013 rate: $19.67 Cost/procedure code: Physical Therapist - G0151 Billing Unit: 15 minute increments SFY 2013 95% of median: $17.37 Less 5%: $0.87 SFY 2013 rate: $16.50 Cost/procedure code: Occupational Therapist - G0152 Billing Unit: 15 minute increments SFY 2013 95% of median: $16.48 Less 5%: $0.82 SFY 2013 rate: $15.66 Cost/procedure code: Speech Pathologist - G0153 Billing Unit: 15 minute increments SFY 2013 95% of median: $17.65 Less 5%: $0.88 SFY 2013 rate: $16.77 Home Health Provider Requirements - Office of the Inspector General’s (OIG) List Screening • Not be on the List of Excluded Individuals (LEIE) • Not be on the Excluded Parties List System (EPLS) - Valid licensure or certification - Verify Nurse Aide Registry - Have a Bureau of Criminal Identification and Investigation (BCII) report - Not be on the National Sex Offender Registry Medicard Waivers - Medicaid Waivers provide alternatives to institutional long-term care through the Family and Social Services Administration office - Waivers allow participants who have disabilities and chronic conditions, to have more control of their lives and remain active participants of their community Level of Care - Classification system used to determine individuals eligible based on medical, functional and/or developmental information. - If the individual meets the level of care required for placement in a facility, they meet the Level of Care for waiver services. Level of Care - Intermediate In the Community - Intermediate LOC (ILOC) considers an indivdual's abillity to perform activites of daily living and self-administer medication - Used for waivers that provide services as an alternative to nursing facility care Level of Care - Intermediate Care Facility for the Mentally Retarded - Intermediate Care Facility for the Mentally Retarded (ICF-MR ) relies on the presence of a developmental disability, economic independence, communication, independent living and personal care - Provide an alternative to institutional care for an individual with mental retardation or developmental disabilities Participant Assistance and Care (PAC) - Basic personal care and grooming, including bathing, care of the hair and assistance with clothing - Assistance with bladder and/or bowel requirements - Assisting the individual with self-medication(if applicable) - Performing household services essential to the individuals health and comfort in the home - Participate in the individual’s ISP meetings if and when the individual requests them to attend - Perform tasks and duties according to the ISP - Document sheets and document all services provided to and on behalf of the individual - Recognize and record changes in the individual’s condition and behavior as well as safety and sanitation - Monitor incidents and take immediate actions when necessary Care Coordination - ISP and POC should be communicated to case manager and organization providing care. • Coordination of services - All personnel furnishing services maintain liaison to ensure that their efforts are coordinated effectively and support the objectives outlines in the plan of care Reporting Incident Reporting (IR) - May be events involving a person with a developmental disability that are not consistent with daily routines, operations, care or habilitation of that person and include any event or occurrence characterized by risk or uncertainty resulting in or having the potential to result in significant harm or injury to an individual including but not limited to IR Examples - Physical, Sexual, and Verbal Abuse - Attempted Suicide - Death - Exploitation - Failure to Report - Known Injury - Law - Medical Emergency - Missing Individual - Neglect - Prohibited Sexual Relations - Rights Code Violation - Unapproved Behavior Support - Unknown Injury - Unscheduled Hospital Admission Medicare Home Health Start Up - New Provider Number - Joint Venture - Purchase Existing Agency - Merger with Existing Agency Industry Assessment - Market Study - Feasibility Study - Business Valuation - Due Diligence Stretegic steps to a home health agency RAMP UP: 0-3 Months - Feasibility study - Business plan - Budget - Establish boards CERTIFICATION PERIOD: 4-7 months - Application - Develop policies - Accreditation selection and submission MEDICARE DEEMED STATUS: 8-12 months - Survey - Operational processes - Quality improvement New Provider Number Pros - Current volume supports it - Can start the process immediately - Lower capital investment lower than purchase Cons - Start up time 9-12 months - Need to develop infrastructure - Lost opportunity costs for time to achieve full expected outcomes Joint Venture - Two organizations that have similar interests, ideas, or visions enter into an agreement to open a new home health agency Joint Venture Pros - Creates opportunity to meet client needs faster than startup - Typically you buy systems and expertise - Can achieve desired financial results faster - Less capital investment initially Cons - Having shared vision and expectations with a new partner - May not have turn key options - Lower rate of return with shared earnings - Dealing with other partner’s quality and reputation Purchase and Merger with Existing Agency Pros - Immediately creates opportunity to meet client needs - Typically you buy systems and expertise - Can achieve desired financial results faster Cons - Finding desirable agency in your location - If agency is not in service area, then value limited to “startup” cost and time - Higher capital costs and related valuation and due diligence expense - Time can be just as long as a Start Up -- Regina Loncaric, Manager 614.222.9070 Regina.Loncaric@plantemoran.com Doug Grimes, Senior Manager 614.222.9171 Doug.Grimes@plantemoran.com Boris Kushnir, Senior Manager 614.222.9045 Boris.Kushnir@plantemoran.com