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For many years, home health agencies (HHAs) have been under intense pressure to reduce utilization. That’s because, under cost-based reimbursement, they were rewarded for serving as many patients and providing as many visits as possible.
Under the Medicare home health prospective payment system (PPS), which includes incentives designed to curtail utilization, the spotlight is now focusing on underutilization, as well as patient dumping and patient abandonment.
Since HHAs that control utilization are likely to show more profit, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) now is worried that agencies will "dump" high-cost patients.
The Department of Health and Human Services’ Office of the Inspector General (OIG) already has indicated that this may constitute fraud. Unfortunately, the CMS survey process is subject to the interpretation of individual surveyors, industry experts say.
The audience with CMS and the OIG was organized by Rep. Bill Thomas (R-CA), chairman of the powerful House Ways and Means Committee, and the Washington, DC-based National Association for Home Care.
Steve Pelowitz, director of CMS’s Office of Survey and Certification, promised to investigate the incidents. He also emphasized that surveyors are obligated to perform entrance and exit interviews and that CMS’s survey role is oversight and reporting, not harassment.
Elizabeth Hogue, a health care attorney in Burtonsville, MD, cites one HHA that received a condition-level deficiency based on abandonment of a patient, even though the patient was transferred to another agency and care was continuously provided consistent with the patient’s plan of care.
To prove abandonment, she says, the OIG must show that providers unilaterally terminated the provider/patient relationship without reasonable notice when further attention was needed. "Abandonment requires unilateral termination of the relationship," she asserts. "Patients who terminate relationships with providers have not been abandoned."
On the other hand, if the agency intends to terminate the relationship because it lacks resources to meet patients’ need consistent with the Medicare Conditions of Participation, the provider’s actions could amount to "patient dumping" from the OIG’s perspective, especially under a system of prospective payments, she adds.
Scott Lara, director of government affairs at the American Home Care Association in Jacksonville, FL, says he remains concerned that under PPS, surveyors and auditors sometimes are on "witch hunts."
"HHAs are being forced to reduce care while at the same time ensuring that patients have the best outcomes available," he asserts.
(See the next issue of Compliance Hotline for tips on how to avoid deficiencies in the home health survey process.)