Home Health & Hospice Week

You can implement changes now in re-action to a proposed class action lawsuit eliminating the improvement criteria for Medicare home care coverage.

Background: In a proposed settlement of a nationwide class-action lawsuit filed last year, the Obama administration has agreed to scrap the practice of requiring many beneficiaries to show a likelihood of medical or functional improvement before Medicare would pay for home care and other post acute services (see Eli's HCW, Vol. XX, No. 37).

If the federal court judge approves the settlement some time in the next few months, as ex-pected, the Centers for Medicare & Medicaid Ser-vices then will revise Medicare manuals and educate contractors, providers, and others on the clarification, says the Center for Medicare Advocacy, which is representing the plaintiffs in the lawsuit.

What now? "The settlement does not change the underlying law and regulations governing the Medicare program," CMA says in a release. "Accordingly, since the Medicare standards of care are not changed, health care providers should implement the maintenance [rather than improvement] standard now."

"Health care providers should apply the maintenance standard and provide medically necessary nursing services or therapy services, or both, to patients who need them to maintain their function, or prevent or slow their decline," CMA advises. "Under the maintenance standard articulated in the settlement, the important issue is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will 'improve.'"

The National Association for Home & Hospice offers further advice. "NAHC strongly recommends that the first thing HHAs should do is re-familiarize themselves with the existing standards," the trade group tells its members. Then agencies should educate their staff on how to document the need for skilled care in maintenance therapy and chronic condition cases, NAHC adds.

"The focus must be on documenting the skill rather than focusing solely on the impact of the services," NAHC counsels. "Those skills are shown in the patient assessment, the plan development, the ability to make judgments on what is working, modality changes where appropriate, and, in some circumstances the hands-on action. Also, patient complications should be a focus where a normally unskilled service requires a skilled person due to the complexities of the condition."

And HHAs need to educate attending physicians. "A special effort is needed to teach the physicians how they must document the need for skilled maintenance therapy or chronic condition nursing," NAHC says.