Medicare Compliance & Reimbursement

Two crucial homebound documentation areas keep tripping up HHAs.

Homebound status might be the HHS Office of Inspector General's newest favorite target for home health agencies -- but are home health agencies ready for the scrutiny?

The Visiting Nurse Association of Central Pennsylvania agreed to pay $685,000 and enter a five-year corporate integrity agreement as part of a settlement with the OIG over homebound problems.

"The agency allegedly billed for home care nursing services provided to patients without properly assessing and/or reporting the homebound status of the patients as required by Medicare," the OIG says in its latest semiannual report to Congress, covering activities from October 2003 to March 2004.

The VNA settled the charges that it submitted false claims to Medicare from January 1995 to December 1999 based on the homebound problem.

In another case profiled by the OIG, Cape Fear Valley Home Health in North Carolina settled charges -- including "documentation and billing irregularities" for patients who weren't homebound -- for $1 million. Cape Fear self-reported the problems, so it received a lighter penalty than it probably would have if the OIG had come knocking first.

"This issue of homebound status continues to dog home health agencies, so agencies certainly need to pay continuing attention to it," warns Burtonsville, MD-based attorney Elizabeth Hogue.

The upcoming homebound demonstration project and recent changes to homebound status to allow for certain absences isn't going to help matters. "The homebound issue is softening, primarily due to positive lobbying by elder groups," acknowledges attorney Elizabeth Zink-Pearson with Covington, KY-based Pearson & Bernard.

But that just means HHAs must be extra careful to document homebound status under the rules that do apply. "The key here is good documentation even if the rules soften," Pearson tells MLR.

HHAs that want to defend their patients' home-bound status - which affects billing and the agency's compliance status - might want to take the step of documenting homebound status on every single skilled nursing visit, Hogue suggests. That's easier to do now that nursing visit frequency has declined under the prospective payment system.

Some of Hogue's clients prompt nurses with visit note questions that must be answered on each visit. The questions include "Since the nurse's last visit, have you left home? If so, where did you go and what did you do? How long were you gone? Did you require assistance? If so, what assistance did you receive?"

The questions get at two important homebound issues -- the patient's functional limitations that support homebound status, and what patients actually are doing. "We have seen patients whose functional status should have kept them at home, but they actually went out every day to the local restaurant for lunch," Hogue cautions.

Careful assessment, and the documentation to prove it took place, may be the only way to head off hundreds of thousands in settlements. "It is crucial that agencies be able to demonstrate that they constantly monitored this issue," Hogue stresses.

Another home care provider settlement over documentation problems underscores how important the issue is, Pearson notes. St. Francis Hospital Inc. paid a whopping $9.5 million to settle problems, including "systematic documentation lapses," in its HHA, hospice and durable medical equipment departments, the OIG report says.

These cases the OIG is touting "outline the ongoing need for Q&Aon patient documentation," Pearson maintains. "In these kinds of cases, if the OIG comes in or if an HHA suspects a problem, all is lost" if there is insufficient or no documentation.

Like Cape Fear, South Carolina-based St. Francis self-reported the problems and thereby received a better settlement. "The self-disclosure approach to internally discovered irregularities should be given serious consideration," the National Association for Home Care & Hospice urges its members. "Self-disclosure has precluded more severe liability risks and high-cost defense activities while allowing providers to put the problems behind them."