Eligibility

Patient Referral and Eligibility

Objectives
1. Define and describe the required plan of care (POC) for Medicare reimbursement (HCFA485). 5

2. Explain the five conditions that must always be met in order for a client to qualify for Medicare reimbursement. 5

Background
Working in home health care stretches the clinical nurse beyond quality professional standards of practice into the challenging realm of reimbursement, economics and state and government regulations. The home health nurse also learns to juggle and balance the clinical and administrative demands of home health nursing. In this module the focus is on patient referrals and eligibility.

Why do I as a home health nurse need to know this?
The home health nurse frequently is the professional making the decision during the first home visit whether or not the patient meets eligibility criteria for their payer. The nurse must be able to clearly communicate with the patient and family the eligibility criteria related to their payer (insurance plan).

Content

1. Referral
A patient referral is the process by which continuity of care is planned and the initial contact is made for providing home health services. Health care personnel, clients or consumers can make a referral. Referrals can be made by nurses, social workers and discharge planners but are generally initiated by a physician. The goal of a home health visit is to render the right services at the right time with a positive client outcome. The two major sources of referral are:

A. Hospital (discharge planner and/or physician)

B. Community resources (nursing homes, agencies, social services offices, family or caregiver).

The referral generally contains verbal or written orders from the physician. If not, the physician must be notified for orders. Orders must be received prior to performing services. After the first visit to the patient, these orders are incorporated into the plan of care (POC) or plan of treatment (POT).

The Plan of Care
This document, also called the HCFA 485 is a tool designed by the Health Care Finance Administration to be used as a generic plan of treatment or care. The "Plan of Care" must be completed and signed by the physician every sixty days. Medicare considers the sixty-day window "an episode of care".Services provided after the Plan of Care expires cannot be considered provided under a Plan of Care. Proper delivery of services and reimbursement are dependent on the accurate completion of the HCFA 485. The 485 must contain all the information pertinent to the client's condition and orders specific to the type of services to be provided, who will provide the services, how often the services will be provided and the length of time the services are to be provided. Before a bill is submitted for payment it must be signed by the physician. To review the form click on the following link.
http://cms.hhs.gov/forms/cms485.pdf

2. Eligibility

All agencies have criteria to determine that eligibility requirements set out by the payer sources and applicable federal and state regulations have been met. Each agency also has criteria for admission related to geographic location, patient safety in the home and staff safety. It is critical that home health agencies admit only those patients whose health care needs can be safely met in their home environment.

3. Criteria and Conditions for Reimbursement

A. Third-party payer regulations

All private third-party payers (insurance plans) have established certain "coverage guidelines" for their members. These policy guidelines define annual limits, deductibles, co-payments, and covered services, which apply to a member's insurance plan. Agency staff may not know what services will be covered, unless they receive the information from the client directly, or they receive authorization for services from a representative of the insurance company.
B. Medicare-certified visits. All patients must meet all of the following conditions:

1) Eligible for Medicare

2) Homebound - the client is considered homebound if:
Leaving the home requires a considerable and taxing effort.
Absences from the home for nonmedical reasons are infrequent and are for a short period of time.
Absences from home care are for the purpose of receiving medical treatment.

3) Under the care of a physician who authorizes services. The nurse and physician collaborate with the client to develop a plan of care that is relevant to the primary diagnosis and prioritized health care needs.

4.) In need of a skilled service (nursing or physical or speech therapy) that is intermittent or part time. Intermittent means that the patient must have a medically predictable, recurring need for skilled services. Part time means that skilled nursing and aide services combined may not exceed 8 hours per day or 35 hours per week.

5.) In need of services that are reasonable and necessary, which are specific and effective treatment for the patient's condition and within accepted standards of practice.

C. Medicaid services. All patients must meet all of the following conditions.

1.) Eligible for Medicaid.

2.) Unable to receive services in an outpatient setting, or the only alternative would be hospitalization or ER services.

3.) In need of services to treat an illness, injury, disability (including mental disorder).

4.) In need of services which are medically necessary, reasonable in amount, duration and frequency, provided under a plan of care on an intermittent basis (up to five visits per day), in the patient's residence.

5.) Unable to perform the services for himself and has no care giver who is able and willing .

D. Private Insurance/Worker's Compensation.

1.) Member/employer pays premium.

2.) Insurance company defines benefits.

3.) Prior authorization usually required.

E. Managed Care:

1.) Patient must be a covered member.

2.) Agency must be part of the insurance company's network

Patient Referral and Eligibility
Objectives 1. Define and describe the required plan of care (POC) for Medicare reimbursement (HCFA485). 5 2. Explain the five conditions that must always be met in order for a client to qualify for Medicare reimbursement. 5 Background Working in home health care stretches the clinical nurse beyond quality professional standards of practice into the challenging realm of reimbursement, economics and state and government regulations. The home health nurse also learns to juggle and balance the clinical and administrative demands of home health nursing. In this module the focus is on patient referrals and eligibility. Why do I as a home health nurse need to know this? The home health nurse frequently is the professional making the decision during the first home visit whether or not the patient meets eligibility criteria for their payer. The nurse must be able to clearly communicate with the patient and family the eligibility criteria related to their payer (insurance plan). Content 1. Referral A patient referral is the process by which continuity of care is planned and the initial contact is made for providing home health services. Health care personnel, clients or consumers can make a referral. Referrals can be made by nurses, social workers and discharge planners but are generally initiated by a physician. The goal of a home health visit is to render the right services at the right time with a positive client outcome. The two major sources of referral are: A. Hospital (discharge planner and/or physician) B. Community resources (nursing homes, agencies, social services offices, family or caregiver). The referral generally contains verbal or written orders from the physician. If not, the physician must be notified for orders. Orders must be received prior to performing services. After the first visit to the patient, these orders are incorporated into the plan of care (POC) or plan of treatment (POT).
	The Plan of Care This document, also called the HCFA 485 is a tool designed by the Health Care Finance Administration to be used as a generic plan of treatment or care. The "Plan of Care" must be completed and signed by the physician every sixty days. Medicare considers the sixty-day window "an episode of care".Services provided after the Plan of Care expires cannot be considered provided under a Plan of Care. Proper delivery of services and reimbursement are dependent on the accurate completion of the HCFA 485. The 485 must contain all the information pertinent to the client's condition and orders specific to the type of services to be provided, who will provide the services, how often the services will be provided and the length of time the services are to be provided. Before a bill is submitted for payment it must be signed by the physician. To review the form click on the following link. http://cms.hhs.gov/forms/cms485.pdf
2. Eligibility All agencies have criteria to determine that eligibility requirements set out by the payer sources and applicable federal and state regulations have been met. Each agency also has criteria for admission related to geographic location, patient safety in the home and staff safety. It is critical that home health agencies admit only those patients whose health care needs can be safely met in their home environment. 3. Criteria and Conditions for Reimbursement A. Third-party payer regulations All private third-party payers (insurance plans) have established certain "coverage guidelines" for their members. These policy guidelines define annual limits, deductibles, co-payments, and covered services, which apply to a member's insurance plan. Agency staff may not know what services will be covered, unless they receive the information from the client directly, or they receive authorization for services from a representative of the insurance company. B. Medicare-certified visits. All patients must meet all of the following conditions: 1) Eligible for Medicare 2) Homebound - the client is considered homebound if: Leaving the home requires a considerable and taxing effort. Absences from the home for nonmedical reasons are infrequent and are for a short period of time. Absences from home care are for the purpose of receiving medical treatment. 3) Under the care of a physician who authorizes services. The nurse and physician collaborate with the client to develop a plan of care that is relevant to the primary diagnosis and prioritized health care needs. 4.) In need of a skilled service (nursing or physical or speech therapy) that is intermittent or part time. Intermittent means that the patient must have a medically predictable, recurring need for skilled services. Part time means that skilled nursing and aide services combined may not exceed 8 hours per day or 35 hours per week. 5.) In need of services that are reasonable and necessary, which are specific and effective treatment for the patient's condition and within accepted standards of practice. C. Medicaid services. All patients must meet all of the following conditions. 1.) Eligible for Medicaid. 2.) Unable to receive services in an outpatient setting, or the only alternative would be hospitalization or ER services. 3.) In need of services to treat an illness, injury, disability (including mental disorder). 4.) In need of services which are medically necessary, reasonable in amount, duration and frequency, provided under a plan of care on an intermittent basis (up to five visits per day), in the patient's residence. 5.) Unable to perform the services for himself and has no care giver who is able and willing . D. Private Insurance/Worker's Compensation. 1.) Member/employer pays premium. 2.) Insurance company defines benefits. 3.) Prior authorization usually required. E. Managed Care: 1.) Patient must be a covered member. 2.) Agency must be part of the insurance company's network