There’s a good reason health care professionals may not know about or understand the new guidelines under the agreement, says Omdahl of 65 Incorporated. Home care providers have spent decades relying on the improvement standard – and changing that “will involve turning the battleship around,” she says.

It’s important to remember that Medicare has several other requirements for payment and those are unchanged by the ruling Omdahl points out. For example:

  • A physician must prescribe home care.
  • A patient must be homebound. Brief, intermittent trips outside the house are OK, but Medicare regulations don’t clearly define “homebound,” she says.
  • The care must be skilled. Medicare will pay for a nurse or therapist, but not for the kind of general care provided by a home health aide, she notes.
  • The care must be necessary and reasonable.

But Omdahl warns, now that the improvement standard is gone, regulators might be even stricter as they evaluate claims against the criteria that remain.

Know Your Options

Patients who were denied Medicare home health benefits under the improvement standard after the lawsuit was first filed in January 2011, have several options, says Letha McDowell, an elder care attorney who practices in Virginia and North Carolina with the firm of Oast & Taylor. Her suggestions range from simple to more involved:

  • Contact the prescribing physician. At the very least, the physician’s order will help establish the need for home care.
  • Contact the home health agency. The agency may refile a denied claim. “If they’re going to get reimbursed, it’s advantageous for them to provide the care,” says McDowell.
  • Contact a third-party for help. Help might come from an elder care law firm, an advocacy organization, or patient care organizations.

If a physician prescribes skilled home care now, patients and their caregivers should ask the physician to tell them specifically what skilled service is needed, recommends Bill Dombi, vice president for law at the National Association for Home Care and Hospice in Washington, D.C. He notes, for example, that teaching a patient exercises to avoid contractures of the hand may require skilled therapy services. By comparison, a patient may not need skilled care to learn and carry out simple exercises that promote mobility and general good health.

If a payor were to raise a question about the need for skilled home care, it would be very helpful to have the physician’s assessment handy up front, Dombi says.

It’s likely that patients with chronic conditions such as arthritis will need skilled home care only intermittently, says Omdahl. After home care is prescribed, one of the first things a nurse or physical therapist will do is conduct a detailed assessment of a patient’s health and describe a personalized plan of care, she explains.

Depending on the individual patient’s situation, that plan of care might call for skilled care. For example, a registered nurse to teach a patient how to administer pain medication, or a physical therapist to help a patient with an assistive device such as a cane or fit the patient with a brace.

Skilled nursing can even include non-pharmacological approaches to pain medication, says Karen Carnes, a registered nurse for Interim HealthCare, a home care group based in Sunrise, Fla. A nurse might instruct a patient on how to use music or guided imagery, for example, to cope with an acute episode of pain.

Almost 1.5 million Americans receive some form of home care every day, and Medicare is the primary payor for about 57 percent of their home health visits, according to a report from the National Center for Health Statistics. Private insurers are not required to adopt Medicare’s guidelines, but in practice they often do, notes Carnes, who in her role as Interim’s chief clinical officer oversees both private and Medicare- and Medicaid-certified agencies. Still, private insurers, the primary source of payment for about 14 percent of visits, never had an improvement standard either officially or in practice, she says.

Patients, health care providers and payors have been embracing the new agreement since the preliminary November 2012 decision. “People are not being cut off as quickly,” says Oast & Taylor’s McDowell.