Posted by: Robert Markette
January 09, 2006

During the course of treating a home health patient, a home health agency will receive a bill from a hospital or other provider for services provided to one of the agencies patients.  For example, I have had clients receive a bill from a hospital for providing a physical therapy evaluation and/or physical therapy treatment.  The bill arrives at the provider’s office with a note explaining that under the home health PPS system, because there is an open home health episode, the agency is responsible for paying for the provided therapy. 

If the agency did not direct the client to the provider as part of an under arrangements agreement, the agency is usually surprised to receive this bill.  This surprise is often due to the fact that the agency could have provided the service if they had been notified that the patient needed the service.

If you receive such a bill, the first thing you should do is check that there is, in fact, an overlapping episode.  I have had clients call after receiving a letter like this and in the process of reviewing the claim, determined that patient was not in a home health episode at the time of the other service.  CMS had either not received notice or had not processed the notice of the termination of the home health episode.  

In other cases, their was an open episode and the patient had been referred for Physical therapy, but had received it from a different provider.  The provider received the referral, provided the therapy, and discovered when they went to bill for the therapy that the patient was on an open PPS episode.  This is unfortunate, because there are two places at which this could have been avoided.  First, the patient’s physician is often the one who referred the patient for the additional care.  The physician should know that the patient is receiving care from the agency and should simply contact them about the need for additional care.  The agency could then modify the plan of care and have the physician sign off on the changes.  You should talk to the physician’s who refer patients to you and educate them about what services are covered under the home health benefit and advise them that when such a service becomes necessary, the physician should contact the agency.

You should also make referring physicians aware that, because these services are part of the home health benefit, if your agency is not equipped to provide them directly, it will have contractual arrangements with other providers to providers these services.  Furthermore, because of these relationships, the agency is in a better position to keep track of the services provided and follow up.  In contrast, if the physician simply refers the patient elsewhere, the agency will not have any idea about these additional services, which may require a change in the home health plan of care.

The other issue in these cases is that the provider could have checked with Medicare prior to providing the service.  This does not seem to be a common practice amongst hospitals and therapy providers, but I have been told my a number of individuals that it is actually a simple matter to check if the patient is on a home health episode.  This is really no different that checking that an individual is covered by health insurance before providing care.  A quick check up front would eliminate a lot of headaches later for all of the parties involved.

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