Medicare Compliance & Reimbursement

Time to beef up documentation showing the need for skilled care in maintenance therapy and chronic condition cases.

Good news for home health providers: You will not forfeit Medicare coverage if your patient does not necessarily improve, thanks to a class action suit. The Obama administration has agreed in a proposed settlement of a nationwide class-action lawsuit filed last year, to scrap a decades-old practice that required many beneficiaries to show a likelihood of medical or functional improvement before Medicare would pay for home care and other post acute services, reports the New York Times.

Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for the services if they are needed to "maintain the patient's current condition or prevent or slow further deterioration," the newspaper says. The proposed settlement, negotiated with lawyers from the Justice Department and the Department of Health and Human Services, was submitted last week to the chief judge of the Federal District Court in Vermont, the Times continues. If she approves it as expected, she would have authority to enforce it for up to four years.

The changes will apply to both fee-for-service Medicare and Medicare Advantage plans, the Times says.

Access, Cost Issues In Dispute

"The agreement will expand access to care for tens of thousands of people with chronic conditions and disabilities and ease the financial strain facing these beneficiaries and their families," cheers Medicare Rights Center President Joe Baker in a release. "People with Medicare can now depend on coverage for services that treat or manage debilitating, chronic illnesses like Alzheimer's disease, multiple sclerosis and Parkinson's disease -- even if the condition is not expected to improve."

An HHS spokesperson told Reuters the proposed settlement "clarifies" existing policy. "We expect no changes in access to services or costs," she said.

But Judith Stein of the Center for Medicare Advocacy, which represented the plaintiffs, expects the change to increase Medicare's costs, she told the press.

Take These Steps Now To Address Clarification Of 'Improvement' Coverage Criteria

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.

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.