Posted by: Robert Markette
October 09, 2006

I read with some amusement this weeks issue of Home health line. My amusement was not at anything Home health line said, as I am a regular reader, but with Cahabas recent homebound sting. It seems Cahaba is concerned that too many patients are receiving home health care on Medicares dime when they are not really homebound.

That is not too surprising, given a number of factors, including the soft heartedness of clinicians, a factor pointed out in the article. Of course, recognizing a beneficiary is not homebound and discharging that beneficiary are two very different things.

The home health benefit has become a tool not just for recovery after illness, but for long term home care for the disabled and those suffering from illnesses like MS. Medicare has recognized that this was not the original intention of the benefit, and, as I recall, indicated they were going to perform a study regarding its use in some of these newer contexts.

For agencies, the practical issue is this many beneficiaries who have MS or other diseases may not really be homebound but are on the home health benefit. This population can be quite vocal and has a number of advocacy groups, including attorneys, ready to step in if they feel any kind of discrimination is occurring. Also, because these kinds of cases tend to be the lower profit or even loss cases, attempting to discharge a patient can lead to accusations that you are doing it for financial reasons.

Although you do not have an obligation to continue serving a patient, you cannot discharge them for discriminatory means. Thus, when you want to discharge a patient who you believe is not homebound, you need to take steps to prevent accusation of disability discrimination.

First, you should document quite clearly what facts lead you to conclude the patient is not homebound. Some of these facts may not have been apparent when you performed your intake assessment. Your clinician may not have thought to ask if the patient travels or drives himself around town. You staff may routinely come to the home and find the patient out of the house or there may be other factors that lead to this conclusion. I have heard of auditors and surveyors informing agencies that the auditor or surveyor did not think the patient was homebound, when that happens, the agency understandable takes action.

Once you have clearly documented the facts that lead you to your conclusion, you should notify the patient either through an expedited determination notice (if you are terminating care due to non-coverage) or an HHABN using option box one, if you are initiating care. The patient can request a demand bill or can appeal the determination decision through the ED process. Remember, the patient is always free to pay for the care out of pocket. You do not necessarily have to discharge the patient, you just want to be sure you are not billing the Medicare for non covered services.

Something else to keep in mind is whether the patient has appealed this decision in the past. Some beneficiaries have already litigated this issue once and had an ALJ determine they are homebound. This can offer you some guidance as the intermediaries are supposed to give this previous determination great weight. While in my opinion such a previous determination is not binding on the agency, it is more difficult for Cahaba or others to penalize you when an ALJ has already ruled a beneficiary is homebound. If you believe a patient may not be homebound, but they have a prior favorable decision, you should ask for a copy of it and discuss the matter with our attorney.

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