In these times of uncertainty and unprecedented disruption, the healthcare industry needs to consider what this new normal will bring to how care is delivered and paid for in the future. The federal and state governments are modifying various rules and requirements to alleviate burdens and enable care, as well as focusing on delivery in alternate care settings such as home health and telehealth. EXL Healthcare has prepared this short brief to share key insights and help our clients prepare for the impact on home health care utilization.
- Expect greater utilization of home health as hospitals and post-acute care facilities become overburdened
- Less acute patients both with COVID-19 and non-COVID-19 will require home-based care
- Amidst a lockdown, home health practitioners might be at risk of contracting and or transmitting COVID-19
- COVID-19 exposure concerns rise for vulnerable patients receiving home health services
- Changes to home health and telehealth payments are unclear
COVID-19 CARES Act – Various Measures Encourage Care in Homes
The Act suspends the 2% Medicare sequestration, increases Medicare reimbursement to providers for COVID-19 patients by 20%, and allows non-physicians to certify home health services
- Enabling Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists to certify services will accelerate treatment in the home and could lead to unnecessary services. This has not yet been implemented into CMS regulations, which could take some time.
- Use of home health care will need to be evaluated and monitored for appropriateness and necessity
CMS’ Changes Enable Increased Utilization of Home Health Services
CMS has relaxed homebound rules
“If a physician determines that a Medicare beneficiary should not leave home because of a medical contraindication or due to suspected or confirmed COVID-19, and the beneficiary needs skilled services, he or she will be considered homebound and qualify for the Medicare Home Health Benefit.”
CMS has increased the ability of Home Health agencies to use telehealth, and also waived co-payments
Home health agencies are permitted to provide “more services to beneficiaries using telehealth,” so as long as it is part of the patient’s plan of care and does not replace in-person visits as ordered on the plan of care.
- The temporary change in the homebound requirement will mean some patients will lose eligibility in the future
- How home health providers will be paid for telehealth visits remains unclear
- CMS plans to treat telehealth as equivalent to a physician face-to-face visit unless an in-person visit is required
Accelerating Payment Requests - Potential need for qualified audits
CMS is making efforts to issue payments within seven days of a provider’s request under an accelerated and advance payment request process
- To qualify for accelerated or advance payments, providers and suppliers must have billed Medicare for claims within 180 days prior to any request
- Providers in bankruptcy or with outstanding delinquent Medicare overpayments are not eligible for accelerated payments, nor are providers under active medical review or program integrity investigation
Key Takeaways for Consideration:
- Given the importance of access to care and the need to keep hospital beds open, many health plans have also removed or altered their normal review and authorization processes for home health care
- The CMS & private health plan changes present an opportunity for providers to over-utilize care
- We would expect some providers to try to represent novel/unapproved technologies as "tele-treatment"
- Increased refusal of care due to exposure concerns will have long term impacts (readmissions etc.)
- Given that some areas of the country are impacted differently, a transparent view of home health related data, such as a heat map, can be valuable in enabling needed care while avoiding inappropriate utilization
- As crisis dissipates, clients should plan for increased utilization review and payment integrity audits
- The need for analytics and resources to identify and investigate potential fraud, waste and abuse will be important