Home Health & Hospice Week

Will you have to secure physician orders for discharged patients?

Home health agencies had a chance to give their two cents on a massive new paperwork burden set to hit this summer - and the feds got an earful.

The Centers for Medicare & Medicaid Services issued a final rule in November 2004 requiring HHAs, hospices and other providers to issue generic termination notices to every single patient they discharge.
 
If the beneficiary decides to pursue a 72-hour expedited appeal of the determination, providers will have to continue services, issue more detailed notices explaining the termination of coverage, and furnish records to the Quality Improvement Organization the same day they learn of the appeal (see Eli's HCW, Vol. XIII, No. 43).

Here are provider representatives' top concerns with the proposed termination notices and expedited review process:

1) Physician orders. The termination notice and expedited review regulation published in the Nov. 26, 2004 Federal Register would require HHAs and hospices to furnish care to patients while their reviews are pending. The problem is that home care providers can't furnish services without a physician's order.

"Providing care without orders is against state law, regulation, and professional practice acts," the American Association for Homecare writes in its letter commenting on the final rule. "It would put nurses and therapists at risk of losing their licenses for engaging in such practices. It would also put the HHA and the employee at risk of litigation."

2) Physician certification. HHA patients can request an expedited review of the termination only if a physician certifies that terminating the services would put the patient's health at significant risk. But CMS has failed to include an explanation of that requirement on its proposed termination notice form, the Illinois Homecare Council notes in comment letter.

"Who is expected to inform the beneficiary of this requirement, and to explain how the certification is to be documented and transmitted to the QIO?" the association asks. "IHCC is concerned that CMS will expect providers to provide this information," further adding to the regulation's burden on agencies.

3) Exclusions. Sometimes issuing a termination notice two days before the discharge date will simply be impossible. For example, when the patient is unsafe in the home or the patient isn't complying with the plan of care, IHCC notes. Or when there is an unexpected hospitalization or the physician terminates services, the Michigan Home Health Association says in its comment letter.

Patient death and the patient terminating her own care are two more circumstances where a two-day-ahead notice is impossible, points out the National Association for Home Care & Hospice. NAHC calls for CMS to officially exclude transfer, death and self-termination as time points notices are required.

4) Timeframe. AAH calls for CMS to expand the requirement to be three days before discharge, so that none of the services would fall outside of Medicare coverage before the QIO decides the appeal. Under the currently proposed set-up, the last 24 of the 72 hours in the appeal timeframe would not be covered by Med-icare. If the QIO upholds the HHA's termination decision, the agency is supposed to bill the patient for any services furnished on that last day.

"The expectation that the home care agency must continue to provide what ultimately will be 'free' service while a beneficiary disputes the termination puts the onus and financial burden on the agency," MHHA protests. "The ability for the agency to then collect on due bills ... will delay monies coming into the agency and prove detrimental to provider operations."

NAHC urges CMS to make clear that providers can furnish the notices ahead of the two-day timeframe if they want to.

5) Work burden. While the patient notice provision is mandated by law, the regulation will add an unacceptable level of work to HHAs' already overburdened shoulders, reps insist. Training staff on the new forms, delivering the notices in patients' homes, explaining them to the beneficiary or her family, preparing and explaining the detailed second-step notice, and reviewing, collecting and sending relevant medical record documentation to the QIO seven days a week is an enormous burden, IHCC insists. 

Editor's Note: The Nov. 26 regulation is at www.access.gpo.gov/su_docs/fedreg/a041126c.html.