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If the Medicare home health prospective payment system (PPS) operates as intended, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) should have no reason to be concerned about patient dumping and patient abandonment, according to home health experts. Nevertheless, CMS has put out the word to state surveyors across the country to crack down on precisely those areas.
CMS wants to avoid overutilization as well as underutilization in home health services. However, veteran home health attorney Elizabeth Hogue in Burtonsville, MD, says finding that middle ground can be difficult. "It is difficult, if not impossible, to articulate what is reasonable, necessary, and appropriate care in terms of national standards of care," she explains.
While surveyors may report allegations of patient dumping to fraud enforcers, Hogue says there are steps that home health agencies (HHAs) can take to avoid or address any deficiencies that may result in the survey process. She says the first step is to understand that surveyors now are more likely than ever to accept the word of patients and their families, especially in surveys based on specific complaints, without first verifying the facts with agency personnel.
For protection, she says agencies should assign at least one staff member to assist surveyors in finding information during the survey. "To the extent possible, these staff members should encourage surveyors to ask for what they need before they reach any conclusions about the agencies’ compliance," she maintains.
When HHAs receive deficiencies based upon erroneous facts, Hogue says they must dispute those deficiencies and request that they be withdrawn. When agencies dispute survey findings but fail to provide corrective action anyway, their plans of correction will be rejected, she cautions.
Under PPS, Hogue points out that providers have fewer resources to provide uncompensated care, and HHAs are more likely to encounter instances when they must terminate services to patients. They also are increasingly exposed to professional liability when they continue to care for patients who are chronically noncompliant.
"Documentation is the key," says Cynthia Hohmann of Health Care Management Consulting, Inc. in Jacksonville, FL. She says it is imperative that HHAs properly inform the patient and family to avoid charges of abandonment. "For the most part, agencies are not abandoning patients," she explains. "In most cases, they are failing to properly document."
According to Hogue, providers who give patients reasonable notice prior to termination will not be liable for abandonment. She says staff members involved in the patient’s care should hold a case conference that addresses the clinical condition of patients, their mental status, and the availability of alternative sources of care, among other factors.
"A reasonable notice period, unless a specified period of notice is mandated by state statute or regulation, is probably a maximum of three to five days for most patients," says Hogue.
After staff members agree on a reasonable notice period, patients and their physicians must be notified verbally and in writing, Hogue says. Given the relatively short notice period, written notice should be hand-delivered to patients and faxed to the attending physicians. "It is unnecessary to put alternative sources of care in place prior to discontinuation of services," she adds.
Another potential problem is care planning that is directed by reimbursement rates, according to Bill Dombi, vice president for law at the National Association for Home Care in Washington, DC. He cites concerns that some HHAs might be devising care plans based on a goal of achieving a certain profit margin on a per-patient basis. Using this approach, an HHA determines the projected PPS payment for a patient following the OASIS assessment.
For example, if the payment expected is $2,000 for the episode and the HHA wants a 10% profit, the care plan is structured to provide only the number of visits that involve a total cost no greater than $1,800.
"While this is not patient dumping, it is another illustration of the quality-of-care risks under the PPS incentives," says Dombi. He says this type of care planning is a recipe for malpractice litigation and survey deficiencies that could lead to termination of the Medicare provider agreement.