SKILLED SERVICE DELIVERY

Medicaid covers all Medicare services but not all Services covered under Medicaid are covered by Medicare. While Medicaid covers custodial services (long-term care) and Skilled Services, Medicare covers only skilled services. Below is a table comparing the services of both Medicare and Medicaid:

Services	Medicare	Medicaid
Medical Supplies and Equipment	Yes	Yes
Nursing	Yes	Yes
Homemaking/Housekeeping	No	Yes
Physical Therapy	Yes	Yes
Home Health Aide	Yes	Yes
Occupational Therapy	Yes	Yes
Personal Care Aide	No	Yes
Speech Therapy	Yes	Yes
Audiology	No	Yes
Respite Care	No	Yes
Meal Delivery	No	Yes

The table above shows the various services covered by both Medicare and Medicaid. We can see that Medicare’s primary focus is on skilled services, meaning services that require some form of certification/license from the individuals who will be administering care to patients.

AUTHORIZATION/REFERRALS/ORDERS

Under the various programs (Medicare and Medicaid), there are different steps you need to take before you begin servicing a client, these steps vary under the various types of insurance and programs in which the client has.

AUTHORIZATION

This sometimes might be termed “prior authorization”, meaning it’s the first documentation given to a provider by the clients’ insurance company to begin services. This document outlines the following:

·        Patient Name

·        Date of Birth

·        Insurance/Medicaid number

·        Authorization number

·        Diagnosis and Procedure codes

·        Requesting Provider

·        Servicing Provider

·        Service period

·        Service Status

·        Service units

The above are the main details you should look out for in an authorization.

Question: What kind of healthcare program gives out authorizations? What are the most important details in an authorization?

REFERRAL

When a hospital or rehab center discharges a patient to home health care, a document is usually sent to a home health agency alongside with the patient’s discharge papers. This document is also known as Referral. A referral is a document that is signed by a physician who is not necessary the patient’s primary care provider (PCP) sent to a home health agency for them to initiate services. A referral must contain the following information:

·        Name of facility

·        Date

·        Name of patient, address and date of birth

·        Patient’s insurance details

·        Order for home health

·        In some cases name of Agency providing home health

Question: Can referrals be used to commence services for a client that is under the care of an HMO? Please explain.

ORDERS

When patients go for routine checks with their doctor, he/she might decide the patient needs some form of home health service. In this scenario the doctor writes an order (like a prescription) to the home health agency explaining the kind of service that the patient needs at that time. In some cases, the doctor leaves the burden of assessment to the home health agency and no specific kind of treatment is ordered. The content of an order is the same with that of a referral; the only difference is that it is coming from a doctor’s clinic who is either the patient’s PCP or a specialist doctor.

Time-line for authorization and referrals: For Medicare patients, the golden rule is that a patient must be assessed and treated by the home health agency within 48hours of receipt of an order or referral from the doctor or hospital. In the case of HMOs or non-Medicare clients, the patient can be seen when authorization is received.

Question: In what scenario would an Agency be required to assess and treat a client without an authorization? What steps do you think the agency should take to avoid citation?

ELIGIBILITY

One thing you should take note: Authorization/Order/Referrals does not guarantee payment!

We already explained the criteria for eligibility for the various health programs within Medicare and Medicaid. But remember there are steps a client needs to take to be a member and remain eligible.

Question: What steps do you think a client who meets the Medicaid or and Medicare eligibility requirements, should take to be eligible for Home Health Care. What factors may cause a client to lose his/her eligibility?

MEDICARE

Medicare requires that an agency run an eligibility check on its members before service commences. Medicare has a 1-800 number in which providers can call in and check for a client’s status and what programs the client is eligible for. The following information is needed to check or verify a client’s eligibility:

·        Name and date of birth

·        Medicare Number

·        Sex

The provider/HHA would also be asked to verify the following information:

·        Tax ID

·        Medicare number

·        National Provider Identifier (NPI) number

Question: What are the benefits of an eligibility check to a HHA?

HMO

The process for eligibility check differs from members under the Medicare Part A plan. In most cases, authorization from the HMO means the patient is eligible for the services described in the authorization form sent to the agency. This is not usually the case. On the portal/website of each HMO, there is an area where eligibility checks on members can be viewed. A copy of this needs to be printed out filed for record purposes.

 SERVICE DELIVERY

Question: What are the main factors to be considered before skilled services be administered to a client?

At this stage the HHA as ascertained the following:

·  

•  HHA has an authorization/order/referral from a certified physician/HMO to commence services
•  Patient is eligible for Home Health service
• Agency is within network to provide services*

ANALYZING THE AUTHORIZATION/ORDER/REFERRAL

Step One: What service is required?

The HHA needs to be sure that the service required to be administered is covered under the contract with the HMO or Medicare

Step two: Does the agency have capacity?

If there order states “monthly blood draw” for 4 months, does the agency have an IV nurse to send to the patient’s home? Is the agency contracted with a lab to analyze the blood?

Step three: Is there a different procedure from Medicare as against HMOs?

United Healthcare still maintains almost the same procedure as per referrals although it has various programs in which it is handling now.

Step four: Are services ordered by the HMO/Physician need to contracted by the HHA to a third party?

If the authorization covers therapy services, the agency needs to ensure that it has reliable therapy company it is contracted who will administer care within the stipulated time frame. The therapy company also needs to have the required insurance needed to cover services for members under the Medicare plan or HMO plan as required.

  

PHYSICIAN APPROVAL

We mentioned earlier that a physician needs to continuously oversee the activities of the HHA agency as it affects the client/member. Some of the ways a physician can monitor these activities is through the following:

•  Plan of Care
• Communication/Progress notes
• Home Health Orders
•  Therapy Evaluations
• Discharge Summary/Re-certification
• 60 day summary

Note: Medicare requires all agencies servicing clients under the Part A program must obtain a document called “Face to Face” from the patient’s PCP within 30 days of servicing the client.