Home Health and Durable Medical Equipment (“DME”) can’t seem to get out of the spotlight and who can blame the government for scrutiny. Back in the day when Home Health charged on a “per visit” basis, we saw independent Home Health agencies in abundance across the United States, company CEOs using Medicare dollars to purchase airplanes and living in mansions as they reaped the benefits of what was found to be Home Health fraud and abuse. In the late 90’s an “interim payment system” was implemented prior to Home Health Prospective Payment and many of the independent agencies closed their doors, CEOs went to jail and those left behind were faced with a unique payment system that challenged agency administrators with “how to run their business under prospective payment.”
If anyone saw “60 minutes” on Sunday, October 25, 2009, the reporters highlighted that an estimated 60 billion Medicare dollars a year is inappropriately paid for DME that was never provided to the Medicare beneficiary. The DME scam artists set up medical supply companies in strip malls with “just enough equipment to pass inspection,” used stolen or purchased Medicare beneficiary lists at $10/patient and used “Medicare codes” to fraudulently bill. Some of the most abused codes were those related to artificial legs, gas-powered arms, electric wheelchairs, etc., according to an individual interviewed who was incarcerated for the crime.
Section 5005 – 5007 of the Senate Finance Committee Bill under Title V: Fraud, Waste and Abuse, target Home Health and DME and specifically discuss the following:
Sec. 5005. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals.
This section requires Home health and DME certifications and written orders to be made by enrolled physicians and health professionals. The proposed effective date for this provision is July 1, 2010.
Sec. 5006. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse.
If a physician or supplier cannot provide documentation to support the referral (access to documentation related to written orders or requests for payment) of Home Health and/or DME, then enrollment from the program may be revoked for a period of not more than one year for each act. The amendments made in this section apply to orders, certifications, and referrals made on or after January 1, 2010.
Sec. 5007. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare.
For Home Health after January 1, 2010, a physician who certifies a patient for home care must have documented a face to face encounter (this can include telehealth) with their patient within six months preceding certification. The current home health rules only state that the patient “must be under the care of a physician”.
For DME, within six months of an order for DME, the physician must document a face to face encounter (or telehealth) with the patient.
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To stay abreast of Home Health and DME Rules and Regulations, the Medicare Benefit Policy - Basic Coverage Rules (PUB. 100-02) Chapter 7 - Home Health Services 30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services and the Medicare Claims Processing Manual (PUB 100-04) Chapter 20 for DMEPOS can be easily accessed through CCH & MediRegs Coding Suites™.
If you are not a current MediRegs customer and are interested in trial access to The Coding Suites™, please go to http://codingsuite.mediregs.com, click on the left nav “Register here” and simply fill out the form.