Tuesday, April 23, 2019

Quality to the Next Level


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Home Health Care Services

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1-931026309 - Friday, February 22, 2013
Rationale for the Referral: Medicare does not pay for Home Health Care services without a physician certification of the beneficiary’s homebound status.  The physician must certify the plan of care within the regulatory sixty-day period, and the verbal start of care date and signature must also be timely.

Referral Document

Appeals Council Decision

 
1-909901595 - Friday, February 22, 2013
Rationale for the Referral: Effective Jan. 1, 2011, CMS changed home health certification requirements from including a physician signature only to including both a signature and the physician’s accompanying handwritten date.

Referral Document

Appeals Council Decision


 
1-858546735 - Friday, February 22, 2013
Rationale for the Referral: For a beneficiary to qualify to receive any Medicare-covered home health services during a given period of time, a beneficiary must need either intermittent skilled nursing services, physical therapy, speech-language pathology, or continuing occupational therapy services (that is, when previous skilled nursing, physical therapy, or speech-language pathology was received and terminated but occupational therapy services continued).  If a beneficiary does not need and receive one of these types of Medicare-covered skilled services, a beneficiary may not receive Medicare-covered dependent care services such as home health aide services during such period.  Additionally, physical therapy services are not covered if they are not furnished pursuant to a valid plan of care.

Referral Document

Appeals Council Decision

 
1-795788489 - Tuesday, November 8, 2011

Rationale for the Referral: Regulations require a physician to identify the medical treatment or skilled service being ordered on a home health care plan of care in more specific terms than “skilled nursing” or “SN.”

Referral Document

Appeals Council Decision

 
1-782344607 - Wednesday, October 26, 2011

Rationale for the Referral: Typed names without evidence authenticating the typed names such as electronic signature and without handwritten signatures do not satisfy Medicare authentication requirements. 

Referral Document

Appeals Council Decision

 
1-765390235 - Thursday, October 13, 2011

Rationale for the Referral: Dates of service prior to October 1, 2007, were included in the Third Party Liability Demonstration Project and not part of the traditional Medicare appeals process.  Because the appellant did not receive a redetermination or reconsideration on the dates of service prior to October 1, 2007, the appellant had no right to an ALJ hearing for those dates.  With regard to the remaining dates of service at issue:  “The absence of a physician certification is not essential to a determination that the beneficiary was homebound for coverage purposes, but such certification is an essential prerequisite for Medicare payment.” Claims for home health care services lacking explicit certifications or any indication the beneficiary was homebound do not meet regulatory conditions for payment.

Referral Document

Appeals Council Decision

 
1-684164749 - Wednesday, October 5, 2011

Rationale for the Referral: A physician must certify and recertify the beneficiary was homebound during the dates of certification at issue as a condition of Medicare payment for home health care services. The lack of a dated physician’s signature or date of receipt on the home health care plan of care invalidates the physician’s certification and the plan of care.  The provider bears the financial burden because it’s the provider’s responsibility to ensure it meets all applicable certifications requirements to receive Medicare payment for covered services.

Referral Document

Appeals Council Decision

 
  
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