Medicare-certified home health agencies are justifiably concerned about recent fraud and abuse initiatives that target homebound status. Agency managers perceive that they are extremely vulnerable regarding this issue for at least two key reasons: (1) the standards used to determine homebound status remain ill-defined; and (2) because Medicare homecare services are provided only intermittently, as opposed to continuously, agencies are unable to verify homebound status with absolute certainty.
Nonetheless, the Health Care Financing Administration (HCFA), the Office of Inspector General (OIG), and intermediaries are intent on holding agencies’ “feet to the fire” on this issue. On October 5, 2020, for example, the U.S. Supreme Court denied review of a provider’s petition that raised questions about homebound status. This means that the lower Court decision from the Fifth Circuit stands [Palm Valley Health Care, Incorporated v. Alex M. Azar, No. 18-41067, U.S. District Court for the Southern District of Texas, January 15, 2020].
Palm Valley Health Care argued that patients are homebound if they should stay at home, even if they don’t actually do so. Palm Valley contended that whether or not patients actually leave home is largely irrelevant; what matters is when beneficiaries have conditions restricting their ability to leave home without assistance.
Palm Valley also argued that HHS lacked substantial evidence for the denial of claims on the basis of homebound status because HHS relied primarily on interviews with beneficiaries who stated that they were not homebound. Their testimony was unreliable, according to Palm Valley, because a significant amount of time had passed between the claims and interviews. The Medicare contractor relied, for example, on an interview with a beneficiary’s daughter two years after her Father received services. The patient’s daughter said that two years earlier her father was able to drive to the barbershop and to visit his daughters.
Generally, Medicare patients are considered to be homebound if they meet the following criteria: (1) patients leave home infrequently for only short durations of time for reasons other than to seek medical care that they cannot receive at home, and (2) when homebound patients leave home, it must take great and taxing effort and/or require maximum assistance. Homebound patients may, however, leave home to attend religious services and adult day care programs that meet certain requirements. The difficulty that agencies have in interpreting these standards is evident. For example, what is a “short duration of time?” What is “great and taxing effort” or “maximum assistance?”
Nonetheless, home health agencies must be prepared to respond to denials of claims based on these standards by addressing two key questions: (1) Do patients’ clinical conditions support a conclusion that they are homebound? (2) What are patients actually doing? Agency managers should take the following actions NOW with regard to what patients are actually doing.
Staff should focus on “beefing up” documentation related to homebound status in the following ways:
- During the admission visit, inform new patients about the criteria of homebound status and document that this information was given to patients.
- Periodically, staff should question Medicare patients, either in person or via telephone, about whether they are homebound by asking questions such as: Have you left home since the last time I talked with you? If so, when? Where did you go? What did you do? How long were you gone? What assistance did you have each time you left home? Some agencies include questions that prompt nurses to obtain this information on every visit. Patients should be asked to confirm with their signatures that the information they provide is complete and accurate.
- When staff members know of patient conduct that may indicate that they are no longer homebound, staff members must immediately report this information to their supervisors and document that they have done so. Agency staff members can no longer afford to turn a “blind eye” or a “deaf ear” to information with regard to this issue. Supervisors, in turn, must investigate information they receive. If further investigation clearly reveals that patients are no longer homebound, supervisors must take action to terminate services to these patients. If, however, further investigation indicates that patients’ homebound status is questionable, the team must hold a case conference to determine together whether or not the patient is still homebound. The results of this case conference must be carefully documented.
Of course, there are no guarantees that patients are telling the truth or that auditors will not second-guess agencies on this issue anyway. The documentation described above, however, makes it considerably harder for auditors to disallow payments for visits, or to find that agencies engaged in fraudulent or abusive conduct.
©2020 Elizabeth E. Hogue, Esq. All rights reserved.