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Study by HHS Office of Inspector General Examines Physician Problems in Home Health Care for Medicare Beneficiaries

December 27, 2001

Study Received Substantial Input from ACP-ASIM

(Washington, D.C.): Physicians are currently playing a key role in initiating, certifying, and monitoring the care for Medicare home health beneficiaries, according to a study released December 20, 2001 by the U.S. Department of Health and Human Services' Office of Inspector General (OIG) entitled "The Physician's Role in Medicare Home Health, 2001." They are doing so, however, despite limited knowledge of Medicare home health rules as well as discomfort with the Center for Medicare and Medicaid Services' (CMS) expectations.

The OIG inspection report focuses on the physician's role in certifying and overseeing Medicare patients' need for home health care services. The American College of Physicians - American Society of Internal Medicine (ACP-ASIM) played an instrumental role in the study's design and content, identifying key issues for the OIG to focus on from a physician's perspective.

"At present, the availability of reimbursement for their oversight role does not seem to have significant impact on physicians who care for Medicare home health patients," said ACP-ASIM President William Hall, MD, FACP. "To address physician concerns and improve the Medicare home health services, however, the ACP-ASIM recommends that CMS establish a working group of its Physician Regulations Issues Team to improve communication and to consider modifying the physician home health oversight role."

The problems identified by the ACP-ASIM included:

  • A lack of adequate home health care information and guidance from the CMS.
  • The complexity of filling out the CMS home health certification and recertification forms, and lack of awareness that CMS now reimburses physicians for completing these forms as well as care plan oversight.

Another major problem identified by the ACP-ASIM involved a common situation where physicians are asked to approve durable medical equipment (such as wheelchairs) for their home health patients, but do not have sufficient knowledge of the differing levels and cost of such equipment to make an informed decision. This can lead to abuse by the requesting home health agency.

The ACP-ASIM's comments on the draft version of the OIG Report are included in an attachment to the final document and include the following recommended changes to CMS' policies.

  • The criteria for determining a patient's homebound status need to be much more clearly spelled out, offering some clinical examples as further guidance.
  • The home health services and durable medical equipment that qualify as medically necessary should be listed, including guidelines on intensity and duration of service.
  • Home health certification/re-certification forms should be simplified so that only essential information about the patient's need for home health services is presented on the forms' face page.
  • An explicit statement of CMS' expectations should be issued for what constitutes appropriate physician care plan oversight of their homebound patients.
  • To encourage greater physician participation in overseeing home health patients, CMS needs to publicize it now offers payment for rendering home health certification and re-certification decisions, as well as enhanced payment for care plan oversight;
  • To deter a home health agency's incentive to under-provide care as a result of the shift to a home health prospective payment system, physicians should be alerted to this potential problem and their heightened vigilance enlisted to ensure patients receive an appropriate level of service from home health agencies.

ACP-ASIM is the nation's largest medical specialty organization and the second largest physician group. Membership encompasses more than 115,000 internal medicine physicians and medical students.

Note to editors: The full OIG report may be downloaded at http://oig.hhs.gov/oei/reports/oei-02-00-00620.pdf

Contact:
Jennifer Whalen, (202) 261-4575
Jack Pope, (202) 261-4556

Page updated: 11-04-03

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