Home Health Care services must be differentiated from a Physician, simply, providing medical care in a patient’s home. One major difference, besides the physical presence of the Physician making a house call, is the “HOMEBOUND REQUIREMENT” for services provided to a Patient in their own home. “Homebound will be discussed shortly.
Under Medicare, a Physician prescribing Home Health Care or Durable Medical Equipment must certify that services or items are Medically Necessary and the Beneficiary meets the requirements to qualify for the benefit.
The Office of Inspector General (OIG), in audits has found that some Physicians are inappropriately ordering Home Health Care and Durable Medical Equipment and supplies for Medicare patients. There appears to be Physicians laxity in reviewing and completing the required certification which has aided fraudulent and abusive practices by unscrupulous suppliers and Home Health providers. Physicians are signing forms provided by Home Health Agencies that falsely represent Patients as needing skilled nursing services to qualify them for Home Health Services. Some Physicians are urged by Durable Medical Equipment suppliers to sign Medical Necessity forms to bill equipment or supplies.
The OIG points out that a Physician is not liable for erroneous claims due to mistakes, inadvertence, or simple negligence, HOWEVER, knowingly signing a false or misleading certification or signing with reckless disregard for the truth can lead to serious criminal, civil, and administrative penalties, including criminal prosecution fines as high as $10,000 per false claim plus treble damages, administrative sanctions, including exclusion from Medicare, withholding or recovery of payments, loss of license, etc. Offenders may be liable even if they did not receive any financial or other benefit from the providers or suppliers.
THE OFFICE OF INSPECTOR GENERAL CAUTIONS:
Do not prescribe services and items as a courtesy to a Patient, Service Provider, or Medical Equipment Supplier without first making a determination of Medical Necessity.
Do not sign false or misleading Medical Certifications knowingly or recklessly.
Do not accept kickbacks (ie cash, gifts, etc.) in return for a signature.
MEDICARE REQUIRES THE TREATING PHYSICIAN TO CERTIFY INITIALLY AND RECERTIFY AT LEAST EVERY 62 DAYS AND THAT:
The Patient is confined to the home.
The Patient currently requires or has needed intermittent skilled nursing care or physical therapy.
All services will be furnished while the Patient is under the care of the Physician.
The order for Home Health Care will be provided orally or in writing prior to the service being initiated. The certification must be signed prior to submission of the claim to Medicare.
MEDICARE’S HOMEBOUND RULE:
When deciding whether to refer a Medicare Patient to Home Health Care, remember that the original intent of the Home Health benefit was not simply to make care available to a beneficiary in the home because it was convenient, but because the beneficiary was homebound and could not get the services unless they were provided in the home. The current definition of “HOMEBOUND” according to Section 2051.1 of the Medicare Carriers Manual is as follows:
An individual does not have to be bedridden to be considered confined to his/her home. The condition of the patient would result in a considerable and taxing effort to leave home. The Patient certainly may, though infrequently, leave the home for periods of relatively short duration. In most instances, absences from the home, would be for the purpose of receiving Medical treatment. Absences from the home for non-medical purposes (e.g. a trip to the barber, a walk, or a drive) would certainly be acceptable.
In general, a Patient will be considered Homebound if he/she has a condition due to an illness or injury which restricts the ability to leave their place of residence except with the aid of supportive devices (such as crutches, canes, wheelchairs, walkers, special transportation), or the assistance of another person, or in which leaving home is Medically contraindicated. An “aged person” is NOT considered justification for Home Health Care. If for any reason a question is raised as to whether a Patient is Homebound, the treating Physician must provide the information to establish “Homebound” as defined above.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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