HOME HEALTH CARE PERSONNEL

The largest number of home care employees are nurses and home care aides (NAHC, 2004).
Registered nurses and licensed practical nurses represent just under half of full time equivalent (FTE)
positions in Medicare-certified agencies. Home care aides, physical therapy staff, occupational
therapists, social workers, and administrative personnel comprise the rest of the home health team.
The business and office personnel of a home health agency are critical to the agency’s ability to
deliver services to clients. Home health nurses must acquire an understanding of the financial
aspects of their clients’ care and provide this information to the agency staff, so that appropriate
and full reimbursement can be obtained for the services provided.

REIMBURSEMENT FOR HOME HEALTH CARE

Home health services are reimbursed by both corporate and governmental third-party payers as well
as by individual clients and their families. Corporate payers include insurance companies, health
maintenance organizations (HMOs), pre-ferred provider organizations (PPOs), and case-
management programs. Government payers include Medicare, Medicaid, the military health system
(TRICARE), and the Veterans Administration system. These governmental programs have specific
conditions for coverage of services, which are often less flexible than those of corporate payers. For
a general description of these reimbursement systems, see Chapter 6. The Medicare policies for
home health programs set the precedent for all other reimbursement sources and are discussed
below

Medicare Criteria and Reimbursement

Medicare is the largest single payer for home care services in the United States and has set the
standard in establishing reimbursement criteria for other payers. Therefore, it is essential that home
care nurses seek to understand the complex Medicare home health requirements and rules for
determining eligibility for home care services. It is important to acknowledge that a person may be in
dire need of care at home, yet not meet eligibility standards for homehealth care under Medicare.
Five criteria must all be met tobe eligible for reimbursement by Medicare (Display 32.1). Consider
the implications of these requirements. Documentation must justify that the plan of care is
medically “reasonable and necessary.” The person must be under the care of a physician. He or she
must be “homebound” and in need of services that Medicare narrowly defines as “skilled.” A person
who is “homebound” must beconfined to home except for visits to the physician, outpatient dialysis,
adult day center, or outpatient chemotherapy and radiation therapy. “Skilled” services are
restrictively defined and include selected aspects of nursing, physical therapy, or speech therapy.
Home visits must be “intermittent” and time limited. Extensive documentation is required according
to Medicare specifications. All of these requirements are subject to contradictory interpretations,
which can put an agency’s reim-bursement at risk. The Medicare Prospective Payment System (PPS)
pays an agency for a 60-day “episode of care.” All services and many medical supplies must be
provided under the payment amount adjusted to geographic location and determined by the
patient’s clinical and functional status at the start of care, as well as the projected need for services
over the anticipated 60-day period. When the patient is admitted, the patient is comprehensively
assessed using a lengthy tool called the Outcome and Assessment Information Set (OASIS). Clinical,
functional, and service scores are calculated from selected OASIS items. In the ongoing campaign to
hold down the federal budget by diminishing health costs, home health care faces the ongoing
threat of freezes or cuts in payment. For example, in Spring of 2007, the Centers for Medicare and
Medicaid Services (CMS) proposed reduction in reim-bursement, justified by their claim that
patients’ needs have been exaggerated in documentation submitted to them (CMS, 2007). They also
require payment adjustment based on agency submission of data on selected quality measures. In
2007, the Medicare Payment Advisory Commission (MedPAC) recommended to Congress that
payments be frozen and that patients co-pay for each illness visit (Markey, 2007). These proposals
overlook the reality that home health care is a cost-effective alternative to hospital and nursing
home care. As home health care is restricted to save money and reduce fraud, greater amounts will
need to be spent for inpatient care when people cannot cope in the absence of health care
assistance at home (see Perspecives:Voices from the Community).

Medicare Documentation

Initially, every patient must be assessed using the OASIS tool, which determines reimbursement, is
integral to agency surveys and certification, and collects information used to measure quality. OASIS
assessment requires combining observation and interview to determine functional status, since
clients often report what they wish to be true, rather than actual ability (Godfrey, 2005). Selected
quality outcomes are measured and data released on the CMS website, which is accessed as “Home
Health Compare” (http://www.medicare.gov/ HHCompare). Display 32.2 identifies selected quality
measures. Note that the expectation is that of improving function, not simply stabilizing function,
and consider the implications of this standard for very disabled patients.The Medicare Plan of Care is
also completed by the nurse at admission; it must be signed by the physician. It is then used to
assess agency complicance with Medicare and state requirements. Obviously, great pains must be
taken to assure accuracy. All follow-up services must match the plan of care. Likewise, OASIS
answers and Plan of Care answers must match.