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How to Avoid False Claims Based on Homebound Status
By Elizabeth E. Hogue, Esq.
Patients must be “homebound” in order to receive home health services under the Medicare Program. Medicare-certified home care agencies are justifiably concerned about the recent fraud and abuse initiatives that target this criteria. When patients are not homebound, but receive services anyway, claims for services provided under these circumstances are false claims.
Agency managers perceive that they are extremely vulnerable regarding this issue for at least two key reasons:
- The standards used to determine homebound status remain ill-defined; and
- Because Medicare homecare services are provided only intermittently, as opposed to continuously, agencies are unable to verify homebound status with absolute certainty. Nonetheless, the Health Care Financing Administration (HCFA), the Office of the Inspector General (OIG) and intermediaries are intent on holding agencies “feet to the fire” on this issue.
Generally, Medicare patients are considered to be homebound is they meet the following criteria:
- Patients leave home infrequently for only short durations of time for reasons other then to seek medical care that they cannot receive at home, and
- When homebound patients leave home, it must take great and taxing effort and/or require maximum assistance. Patients may, however, leave home to attend adult day care programs that meet certain requirements and religious services and remain homebound.
The difficulty that agencies have in interpreting these standards is evident. For example, what is a “short duration of time?” What is “great and taxing effort” or “maximum assistance?”
Although agencies talk in terms of recent changes in these standards, the fact of the matter is that the standards summarized above have been the same for some time. What has changed, however, is that regulators are determined to more strictly apply these standards.
Home health agencies must be prepared to respond to more strict application of these standards by addressing two key questions:
- Does the patient's clinical condition support a conclusion that the patient is homebound?
- What is the patient actually doing?
Agency managers should take the following actions NOW:
1. Encourage staff members to spend less time and energy trying to understand how to interpret the standards summarized above. The standards remain difficult to understand, interpret and apply. Even when staff members call regulators to ask for clarification or for determinations about specific cases, they may receive different answers, depending upon the person with whom they are speaking. In addition, staff cannot rely on verbal guidance given by regulators.
2. Instead, staff should focus on “beefing up” documentation related
to homebound status in the following ways:
- During the admission visit, inform each new patient about the
criteria of homebound status and document that this information has
been shared. Continuous quality improvement (CQI) staff members
should audit retrospectively to verify that this information is
provided to each new Medicare patient.
- Periodically, visiting staff should interview Medicare patients
either in person or via telephone regarding whether they are
homebound by asking pointed questions such as: Have you left home
since the last time I talked with you about this issue? If so, when?
Where did you go? What did you do? How long were you gone? What
assistance did you have each time you left home? It may be
helpful to ask nurses to obtain this information during supervisory
visits. Some agencies include questions that prompt nurses to obtain
this information on every visit. In addition, CQI staff should audit
to make certain that this task is accomplished.
- When staff members know of conduct of patients that may indicate
that they are no longer homebound, they must report this information
to their supervisors immediately. Agency staff members can no longer
afford to turn a “blind eye” or a “deaf ear” to information that
comes their way about this issue. Staff must document that they have
done so. Supervisors, in turn, must investigate information
they receive related to this issue. If further investigation clearly
reveals that patients are no longer homebound, supervisors must take
action to terminate services to these patients. If, however, further
investigation indicates that patients’ homebound status is
questionable, the team must hold a case conference to determine
together whether the patient is still homebound. The results of this
case conference must, of course, be carefully documented.
- Agency staff should also continue any documentation related to homebound status that they currently produce, including documentation of patients’ functional limitations.
The documentation described above must be written in plain English in enough detail so that regulators who know very little about health care, much less home care, can readily see that agencies have been continuously monitoring patients' homebound status.
Of course, there are no guarantees that patients are telling the truth or that auditors will not second guess agencies on this issue anyway. But the documentation described above makes it considerably harder for auditors to disallow payments for visits or to find that agencies engaged in fraudulent or abusive conduct.
(To obtain a copy of Medicare/Medicaid Fraud and Abuse: A Practical
Guide for Providers, send a check for $25.00, including shipping and
handling, to Elizabeth E. Hogue at the address below. To obtain a copy
of How to Develop a Fraud and Abuse Compliance Plan, send a check for
$55.00, including shipping and handling, to Elizabeth E. Hogue at the
above address.)
Copyright, 2001.
Elizabeth E. Hogue, Esq.
All rights reserved. No portion of this material
may be reproduced in any form without the advance written permission of
the author.
Reprinted with permission by Leading Home Care.
15118 Liberty
Grove
Burtonsville, Maryland 20866
Office: 301-421-0143
Fax: 301-421-1699