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Holt says the allowable benefits are thus broader than people realize. Home health agencies routinely decline to provide even the skimpier services that Medicare publicizes to Medicare enrollees who request them. Significantly, Medicare will only pay insurance claims to home health agencies who are registered and approved by Medicare.
Ostensibly to help consumers, it has developed an extensive quality rating systemso consumers can find the most qualified agency. However, there apparently is no requirement that an agency actually provide home health services when Medicare enrollees request them.
This is an admirable goal, but what it means is that home health agencies are rewarded for treating patients who are likely to get better. Supporting care that cures people, while understandable, is not a requirement Medicare insists on for covering most health care. However, Medicare and Congress have supported the shift from fee-for-service health care to fee-for-results care.
In this situation, home health agencies face a carrot-and-stick financial incentive system based on measurable patient improvement. Does my mother qualify for home health care? This latter group, of course, is filled with growing numbers of older Medicare beneficiaries. Overwhelmingly, such people would like to stay in their homes, and getting home-based care would help make this possible. While Medicare stresses that the benefit should be considered a short-term solution, Holt notes that it can be renewed for consecutive day episodes of care.
So long as a doctor prescribes continuation of such care, Medicare is supposed to cover it. Care lasting beyond 60 days has become a red flag that triggers a fraud investigation by the outside fraud contractors hired by Medicare, she says.
Needless to say, home health agencies are not eager to have their Medicare licenses threatened by having a fraud bullseye painted on their backs. The common response to all of these forces is for home health agencies to either physically or figuratively just not come to the phone when Medicare enrollees come calling looking for care.
And this, the Center for Medicare Advocacy has found, is exactly what has happened. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient.
The development of a personal relationship with the provider's personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care' setting.
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If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider's service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect "problem" employees, and to ensure no incident has taken place that might give rise to liability.
The home health agency should continue providing care to the patient until definitively told not to do so by the patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately.
Many seniors who qualify for home-based care under Medicare aren’t receiving it. Why?
The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report.
If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.
Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something elseor consistently noncompliant patients.
Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided. As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried.
Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken: The circumstances should be documented in the patient's record.
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The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter.
A copy of the letter should be placed in the patient's record. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient's obtaining replacement home health care should be emphasized.
The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.
A copy of the letter should be sent to the patient's attending physician via certified mail, return receipt requested.
These steps should not be undertaken lightly. Before such steps are taken, the patient's case should be thoroughly discussed with the home health provider's risk manager, legal counsel, medical director, and the patient's attending physician. The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment.
When a physician's order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. Liability to the patient for the tort of abandonment may also result from the home health care professional's failure to observe, examine, assess, or monitor a patient's condition.