Home Health & Hospice Week

HHAs should redouble efforts to furnish virtual visits — and report data on them accurately, expert urges.

Telehealth utilization in various forms has skyrocketed under COVID, but home health agencies are still left out in the cold on reimbursement for such visits.

Many of the commenters on the home health proposed payment rule for 2021 implored the Centers for Medicare & Medicaid Services to implement direct payment for telehealth visits. “Since the beginning of the pandemic, we and other HHAs have urged CMS to allow home health visits delivered virtually to be treated the same as if they were delivered in person,” said Marki Flannery, Visiting Nurse Service of New York CEO, in the agency’s comment letter. “What we are asking for us is no different from what CMS granted other healthcare providers during the [public health emergency] — fair and appropriate reimbursement to care for patients in the safest and most effective manner possible, whether in-person or remotely,” Flannery maintained.

“Not allowing virtual visit reimbursement … places HHAs at a major disadvantage with other entities that are providing home-based technological health solutions,” Flannery added.

“Home health can provide skilled services via telehealth/ remote patient monitoring to the patient in the patient’s home, just as can be done via hospitals, outpatient rehab facilities, etc.,” accountant John Reisinger with Innovative Financial Solutions for Home Health in Tampa, Florida, said in his comment letter. “To not allow this level of service for the home health industry, while allowing it for other segments of the Medicare benefit is injudicious at best, and systemically biased at the worst. This must change,” Reisinger told CMS.

In its comment letter, Louisiana health system Ochsner Health pressed CMS on the issue. “As a national leader in digital and telemedicine, Ochsner strongly believes in our ability to provide the same high-quality care via remote technology as we do in person. Virtual visits have proven to be critically important during the pandemic, where we have seen firsthand that patients are refusing in-person visits out of fear of contracting the virus. Allowing providers to conduct these visits virtually and have them be considered bona fide encounters under the payment system would ensure that patients receive the care they need,” Ochsner told CMS.

The agency may actually agree with some commenters’ points. But direct reimbursement for telehealth visits is out of its hands, CMS emphasizes in the final rule published in the Nov. 4 Federal Register. “By law, services furnished via a telecommunications system cannot be considered a home health visit for purposes of eligibility or payment,” it says.

Despite the lack of reimbursement, HHAs should still use virtual visits, CMS urges. “The use of telecommu­nications technology in furnishing services in the home has the potential to improve efficiencies, expand the reach of healthcare providers, allow more specialized care in the home, and allow HHAs to see more patients or to communicate with patients more often,” the agency says in the rule.

The lack of direct reimbursement and the inability to count the visit toward the low utilization payment adjustment threshold makes that difficult for agencies.

“There is absolutely no reason that CMS doesn’t reimburse for healthcare delivered remotely in home health,” stresses Sharon Litwin with 5 Star Consultants, which has been acquired by Healthcare Provider Solutions. It’s “unbelievable that they won’t apply the remote visit to the LUPA threshold,” Litwin tells AAPC.

“This is the worst. A phone call to a patient is not just saying ‘hi, how are you,’” Litwin says. “It is a clinical visit — spending time going over progress to goals, education, meds, all other interventions, etc.,” she continues. “It is on the plan of care. So how they cannot reimburse or count towards a LUPA is beyond me,” Litwin blasts.

“Given the breadth of types of telehealth visits for which CMS now provides reimbursement, there is simply no excuse for excluding home care providers,” maintains Washington, D.C.-based healthcare attorney Elizabeth Hogue. “CMS should clearly provide reimbursement for telehealth encounters between home health providers and their patients.,” Hogue believes.

“Home care providers need all of the possible ‘arrows in their quivers’ to care for as many patients as possible at home,” Hogue emphasizes. “Home is now very clearly the best place for patients in terms of their safety.”

Unfortunately, CMS is correct that current law prohibits direct reimbursement for home health telehealth visits, notes attorney Robert Markette Jr. with Hall Render in Indianapolis.

“That a telehealth visit does not replace (for purposes of payment/LUPA status) an in-person visit, still significantly hampers its usefulness,” laments Joe Osentoski with Gateway Home Health Coding & Consulting.

But a potential solution is on the horizon. “There is legislation pending in the House and Senate that would provide Medicare with authority to pay for telehealth under the home health benefit” — S. 4854 and H.R. 8677, points out National Association for Home Care & Hospice President William Dombi. It’s possible “that the legislation could be included in a lame duck session bill that funds the government after Dec. 11 and provides stimulus relief,” Dombi tells AAPC.

Stay tuned: “We will have a better sense as to whether that possibility can become a probability once Congress is fully back in D.C.” Dombi says.

Law- and policy-makers can consider a slow start for home health telehealth if they are nervous about it, Hogue offers. “Reimbursement for telehealth visits for home care providers doesn’t have to be an ‘all or nothing’ approach proposition,” she says. Medicare could dip its toe in the home health telehealth waters by initially reimbursing “for a certain number of telehealth visits during an episode, for example, or for certain types of visits,” she suggests.

Keep Your Eyes On The Telehealth Prize

While Congress and CMS hammer out the details, HHAs should stay focused on enhancing their telehealth presence, Markette advises.

Another provision in the final rule points out that the new home health cost report form released Oct. 2 has a new General Service cost center for “Telecommunications Technology” in Worksheet A, Line 5 (see HCW by AAPC, Vol. XXIX, No. 38).

The rule finalizes “regulation text changes allowing a broader use of telecommunications technology to be considered allowable administrative costs on the home health cost report,” CMS notes. “We proposed to amend § 409.46(e) to include not only remote patient monitoring, but other communication or monitoring services, consistent with the plan of care for the individual.”

Signal: “Collecting cost data is an indicator of future plans to reimburse,” Markette believes. “This shows that CMS recognizes the benefits of telehealth in home health. This is another step forward.”

Collecting and reporting this data is an important opportunity, Markette stresses. “As we continue to properly and effectively utilize telehealth to support our patient care, the case for making telehealth a formal part of the home health benefit, including for reimbursement, will become stronger,” he says. “We need Congress to act, but while we are working on that, agencies need to be utilizing RPM and documenting the benefits to patient care.”

CMS “opened the floodgates on telehealth in the spring,” Markette adds. Good resulting data will allow HHAs “to advocate for telehealth going forward, because we would have real data to show for our efforts,” he says.

Caution: HHAs must take care not to squander the opportunity. “My concern is that, without payment now, agencies are not inclined to use telehealth and the data collected will not be a true representation of what appropriately used telehealth could look like in home health,” shares industry veteran Cindy Krafft with Kornetti & Krafft Health Care Solutions.

To do: “As an industry, we just need to keep our eye on the goal and continue to utilize technology,” Markette counsels. “Remote patient monitoring and similar tools are not going away. They are going to be more and more important each year.”

Note: The new cost report form and instructions are at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Transmittals/r1p247.