Home Health & Hospice

What if the Physician Alters the Plan of Care Certification?

Homecare Insider, September 21, 2009

An agency must comply with many requirements when providing Medicare services.  Consider this conundrum.
We have a referral for a patient who resides in assisted living.  She is confined to a wheelchair most of the time, but does ambulate very short distances with a walker.  She becomes extremely short of breath with any ambulation.  She attends a licensed adult day-care three days a week.  We admitted the patient, discussed the plan of care with the physician, and sent the plan for signature.  The physician signed the plan but marked through the homebound information in Locator 26.  When we called him to explain that it makes the form invalid for billing Medicare, he said he doesn’t think the patient is homebound and he won’t sign that she is.  This is our first referral from this new physician, so we don’t want to upset him.  However, we don’t want to have our payment recouped either.  What should we do?  Should we have the patient sign the HHABN?  Or should we just bill the claim?  After all, we do have signed orders.

This agency has signed orders, but it fails to meet a very important requirement for providing services and billing.  When a physician signs a plan of care, he or she certifies that the patient is confined to the home and needs skilled, reasonable, and necessary care.  If the physician alters or crosses out that statement, he or she is not certifying that the patient is confined to home, and the agency is left with a significant problem.

If the patient truly qualifies for Medicare coverage, this administrator should have an open discussion with the physician.  Inform him that the patient may attend a licensed, certified, or accredited day-care center to participate in medical, psychosocial, or therapeutic treatment, with no impact on the homebound determination.

If the physician continues to refuse to certify the patient, the agency should inform the patient that Medicare requires the physician certification.  Encourage her to discuss the problem with the physician.  Explain that she also has the right to call Medicare about the issue.  Perhaps there is another physician willing to serve as the attending physician for homecare.  A second option (and likely last resort) would be to issue a Home Health Advance Beneficiary Notice (HHABN).  The reason for noncoverage would be the physician refuses to certify that the patient is homebound.  Make certain the patient understands that, although you believe the services would otherwise be covered, absence of the physician certification may lead to denial, in which case the patient would be responsible for payment.  Document within the record the discussions, specifically noting the reason the physician refuses to certify the patient.

Every month, HOMECARE ADMINISTRATOR tackles a “Compliance Conundrum.”  Learn more about this newsletter.