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Reimbursement:

Once Is Not Enough For Skilled Nursing Visits

Published on Tue Aug 05, 2003

Sending a nurse on an unreimbursed patient visit can be a financial drain - or a golden opportunity.

Home health agencies' inability to bill Medicare for referrals where only a single skilled nursing visit is required continues to confuse agencies, judging by the number of questions on this topic the Centers for Medicare & Medicaid Services fielded in the July 2 Home Health Open Door Forum.

Some of the confusion may stem from the fact that single therapy visits are reimbursed, speculates consultant Rose Kimball with Med-Care Administrative Services in Dallas. But skilled nursing must be intermittent - which requires more than one visit - to qualify a patient for the home health benefit, she explains. For a single skilled nursing visit to be reimbursable, "you must have a high expectation and probability of making another visit and then something unforeseen happens" to prevent the second visit, Kimball explains.

Intake RN May Improve Process 

The cost of a single skilled nursing visit made without the expectation of more visits, or in which the patient is not admitted to home care, becomes part of your agency's overhead expenses (see chart "Simplify Single Visit Confusion").

Two scenarios account for these costly nursing visits: patients who are referred and visited but not admitted and patients who are referred only for one skilled nursing visit. These situations can be minimized, but not completely avoided.

To avoid wasting time and money, experts suggest you:

  • Screen referrals. Having as much information as possible up front is your first line of defense, says consultant Terri Ayer with Tucson, AZ-based Ayer Associates.

    Try to determine if the patient is eligible for home care and if there is a caregiver available.

    Provide cues for intake staffers to trigger better questions of the referral source, suggests Rachel Hammon with the Texas Association for Home Care.

    And consider using a registered nurse in your intake process, since RNs often know what questions to ask to get the best information, Hammon adds. But "you can't really get in the business of saying you decline referrals," she warns. There must be an acceptable clinical reason, not just a reimbursement concern.

    If the patient needs services you can't provide or has problems that can't adequately be cared for at home, you may be able to determine that without making an assessment visit. But remember some ineligible patients may need an "eyes-on" assessment before determining their needs, Kimball says.

    TIP: If you find you're receiving a high percentage of ineligible referrals from one source, that indicates a need for further education for that source on appropriate cases for home health care.

  • Have decision points. Teaching staff to carefully consider at the time of referral whether you're likely to be able to meet the needs of this patient is the first step, Kimball says. But the second is teaching the admission nurse to evaluate the patient in a general way before going through the whole process of obtaining signatures and doing the assessment and admission. Does the patient live alone? Is intermittent nursing care sufficient? Does the functional level of the patient and the ability of the caregiver make it likely the patient can be cared for adequately at home? Is the patient really homebound?

  • Use salaried nurses wisely. When salaried nurses do the admission visit rather than contract or per-visit staff, a decision not to admit the patient doesn't add to your salary expenses, Kimball notes. For the same reason, if you know you have a one-time-only visit, use a salaried nurse.

  • Consider the visits advertising. It may help to view these single visits as a way to market your agency, experts suggest. "You get your name out in the community and leave your material with someone who may need you later or refer others to you," Kimball notes.

    Accepting these referrals also shows your sources you are community service oriented, and that may encourage future referrals, Hammon says. Depending on the quality of the referral source, the public relations value may make up for "eating the cost of the visit," Ayer adds. But be sure you're not advertising that you provide the first visit at no charge or it may look like a kickback, experts say.

    TIP: If you accept 100 percent of your referrals, consider whether your referral sources are being too conservative and may not be referring eligible patients, Kimball advises. They may need further education about the home health benefit.

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