According to advocates for seniors and the home care industry, Medicare does cover home care services for patients who qualify, but incentives intended to combat fraud and reward high-quality care are driving some home health agencies to avoid taking on long-term patients who have debilitating conditions that would not get better.
The investigators feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes. The group is considering legal action against the government. Federal law requires Medicare to pay indefinitely for home care — with no co-payments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty.
They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement. Those who qualify can also receive an aide's help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.
The government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home —to maintain a patient’s abilities or to prevent or slow decline. It also agreed to inform providers, bill auditors and others that a patient’s improvement is not a condition for coverage.
Medicaid, the federal-state program for low-income adults and families, also covers home health care and other home services. Yet a Medicare official did not acknowledge any access problems. A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit.
But a leading industry group contends that Medicare's home health care policies are often misconstrued. One of the myths in Medicare is that chronically ill individuals are not qualified for coverage, said William Dombi, president of the National Association for Home Care and Hospice.
Part of the problem is that some agencies fear they won't be paid if they take on patients who need their services for a long time. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible or they suspect billing fraud.
Rather than risk not getting paid, some home health B stay under the radar by taking on fewer Medicare patients who need long-term care. Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time.
Another factor that may have a negative effect on chronically ill patients is Medicare's Home Health Compare rating website. It includes grades on patient improvement, such as whether a client got better at walking with an agency's help. That effectively tells agencies who want top ratings to go to patients who are susceptible to improvement.
Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don’t will pay penalties. Some criteria used to measure performance depend on patient improvement. Another new rule prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor's order. But that, too, could backfire.