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Outpatient Therapy While Beneficiary is Under Home Health Plan of Care

September 20, 2013 25 Comments

Fotolia_48966189_XSRAC ‘n Rehab© Series Does this sound familiar?  A patient comes into your outpatient therapy clinic and states they are not receiving any home health.  You are checking because you know if that the patient is receiving home health therapy, that they can’t also receive outpatient therapy, right?  STOP right there.  Even if a patient has stopped therapy under a home health plan of care but is still receiving other home health services (such as nursing services), the home health is being paid under a Part A consolidated billing payment.  So even if the beneficiary had never received therapy (perhaps just wound care by nursing), the home health agency that receives the payment is responsible for therapy, and CMS will not separately pay an outpatient provider for services covered under the consolidated billing rule.  Many clinics know this and try their best to quiz the patient on this, and even check with family.  Most Medicare Administrative Contractors have their system programmed with edits that will prevent the payment, so at least you have not received payment that you will have to refund.

However, not is all that easy…… Performat, the Region A Recovery Auditor (RAC) has a CMS approved issue for automated review that involves payment to private practice for outpatient therapy while a beneficiary is under a home health plan of care and subject to consolidated billing rules.  If you are a provider in DC, DE, MD, NJ, PA, and have received payments for outpatient therapy under the Part B outpatient therapy benefit, and the patient was currently receiving home health under a Home Health Plan of Care (a Part A benefit), the money will be recouped via a demand letter.  This is an issue that is an automated review, meaning that no medical records will be requested and/or reviewed. You may receive a recoupment letter even if you did not know that the patient was under a home health plan of care, even if therapy was not part of the HH POC, or therapy had been discharge but the patient was still receiving other HH service. It was the unfortunate mistake of the Medicare Contractor who paid a claim that should not have been paid, however if you received payment, you were not entitled to it and it will be recouped.

Oh – and by the way – even if the patient wants to come to your clinic, the only way you get paid is to negotiate for payment with the home health agency that is receiving the consolidated payment for the episode.  If you provide services and your claim is denied, you cannot hold the beneficiary liable.

Moving forward, all outpatient therapy clinics should double check their admission procedures to ensure that beneficiaries are not currently under a home health plan of care, and additionally ensure that any home health episode has been discharged.

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (25)

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  1. anamarie says:

    I recently had a patient who came into our clinic, when asked if she was receiving HH she said no. A few days later a HH nurse contacted me stating that the patient wasn’t feeling well and wouldn’t be in for her appt! Come to find out the patient was receiving both HH and Private Duty services and thought they both were ‘private duty’! Of course Medicare didn’t have any posting that the patient was receiving HH in their system…so needless to say our clinic got screwed, through no fault of the patient OR our Admissions Dept.

  2. Nancy says:

    Indeed this is a problem for all therapy providers, and unfortunately you cannot ask the patient to pay for this, or even offer an ABN to “cover” in the event of an active HH episode. That is why a great authorization process, particularly post surgery, must address these issues in several different ways: ask if therapy was received in the home, and also ask was anyone in your home following your surgery (to do a dressing change, to assist you with self-care, to managed your medication etc).

  3. A similar situation happened to me about a decade ago: Medicare did not have the HHA listed because the HHA was behind in submitting claims to Medicare. The PCP did not know another physician had prescribed HHA. My patient was cognitively impaired and family (not local) did not understand the Medicare Part A vs. Part B system constraints.. You absolutely can receive payment from Medicare for this type situation if you sufficiently prove that you provided the services in good faith. In my situation I took my case all the way up to an administative law judge and won my case and was fully repaid. You will have to decide if it is worth your time and emotional energy to go through the Medicare appeals process. I have found it worthwhile and would enourage you to consider standing up for yourself.

  4. MATT MALABY says:

    What if the home health service does not offer a service(ex: aquatic therapy) but an outpatient physical therapy can provide? Would this in terms qualify outpatient physical therapy for payment?

  5. Hi Matt, and thank you for your question. The scenario that you are presenting is very probably. However once a beneficiary is under a home health plan of care all therapy services must be provided under that plan of care under the auspices of the home health agency (HHA). If the HHA included aquatic therapy in the plan of care that would have to either provide aquatic therapy or make arrangements for aquatic. That means they could sub-contract an aquatic therapy provider to provide this service. The home health agency would then reimburse the aquatic therapy provider.

    Please keep in mind that a Medicare beneficiary cannot simultaneously be in a home health episode and in an outpatient therapy episode. The outpatient therapy episode will deny (or be retroactively denied if paid). In order for the outpatient therapy provider to be paid for aquatic therapy services while a Medicare beneficiary is under a home health plan of care is for the HHA to contract for the provision of services. I hope this answers your question.

  6. Desiree says:

    Can a medicare beneficiary have both home health and outpatient wound care at the same time and both entities get reimbursed?

  7. A beneficiary cannot be under a home health plan of care and an outpatient therapy plan of care at the same time. Unfortunately it is the outpatient therapy services that will be denied. Additionally you cannot ask a beneficiary to sign an ABN for the OP services. The HHA is obligated to provide the services, and if they cannot provide the services, they may contract with another provide to provide them, and then pay that provider. Good luck!

  8. CMHC says:

    We have had multiple clients in medicare episode going to wound clinic two to three times per week in between skilled homecare nursing……if we get the medicare payment how do they bill??

  9. Carol says:

    Is there a wait period between the time the patient stops home care and the time they can start outpatient services? My boss has always told me that we need to wait a week between the patient’s last home health visit and the start of outpatient therapy.

  10. julie says:

    We have debridement and some PTS that are being denied. Pt went to Hosp. can we bill back to the HH agency?

  11. Tracy, thank you for your post. I am not quite sure that I follow everything. Are you a HHA? Where is the wound clinic? Is it a therapy clinic billing “sometimes” therapy codes, or an outpatient hospital clinic subject to the OPPS?

  12. Carol, thank you for your comment. Providers should ensure that the home health agency has discharge the patient from their home health (Part A) episode of care. The discharge must also be transmitted to CMS by the HHA. Providers continually report that even after being told by the HHA that the patient has been discharged, that outpatient therapy claims have been denied and/or recouped. This is largely due to the fact that the patient’s discharge has not been properly coded to CMS. While waiting a week many provide a “cushion” in time, it is not a guarantee that the HHA has processed the discharge.

  13. Julie, thank you for your comment. Unless you have entered into an arrangement in which the HHA contracted with you to provide wound services, there is no obligation on their part to reimburse your facility. If you anticipate providing wound services to HHAs in the future I would suggest some pre-emptive planning on arrangement and payments for services.

  14. R.Padin says:

    What if a physician performed the wound care in an outpt setting while the patient was receiving home health care? Shouldn’t that be covered?

  15. As a point of reference, wound care is not an “always therapy code”, it is only a therapy code when performed by a PT under a POC. Additionally if the patient needs wound care, and the HHA cannot provide the WC in the home, they must make arrangements with another provider to do so. It is not a matter of what is covered, it is a matter of who has the responsibility for providing the services under arrangement with the HHA.

  16. D B says:

    Re: your assertion that “If you provide services and your claim is denied, you cannot hold the beneficiary liable”, could I find that info directly on the Medicare website, for example?

  17. Thank you for your comment, and yes you can find detailed information in the statute as well as in the sub-regulatory guidance regarding home health as noted in the original 2013 article.

  18. JR says:

    To the point of the previous comment RE:your assertion that “IF you provide services and your claim is denied, you cannot hold the beneficiary liable”, I can not find that in any documentation. Do you have a link that you could send me?

  19. JR – Thank you for your comment. The links, including the CMS approval to the RAC to post the issue are included in the original post. The RAC posting provides all the regulatory and sub-regulatory references for their authority to audit this issue. In short – all the links have been provided that will confirm that a patient who is under a home health plan of care may not separately receive outpatient therapy services wherein that provider can bill and receive reimbursement.

  20. Nancy says:

    Our Physical Therapy patients often come with the Discharge notifications from Home Healthcare showing discharge prior to the Evaluation. Medicare’s site still shows the patient as 30-Still Patient and until it changes to 01-Home we can’t bill out our claims without getting denials. Sometimes this change over takes 90 days. Is there anything we can do to speed this up? Someone mentioned that there was a code we could use on the claims.

  21. We deal with the HHE situation a lot with out PT clinics. We are diligent to check for HHE dates. I just had one where the patient’s end date (which did not show in CWF when the patient started care) was exactly the same as the patient’s start date with our clinic. I haven’t been able to find anything concrete on CMS site regarding this. Medicare recouped the funds, but I am not certain they should have. Do you know if the end date for a HHE can also be the start date for outpatient care in a private therapy clinic, and if so where is the CMS reference to it?

  22. Rebecca says:

    I have the same question as Nancy from June 23, 2016. This patient has been off home care since 3/1/16 but is still showing up as 30-Home care patient. Can I code something in my bill so I can get paid?

  23. Hi Rebecca. This is a huge dilemma for outpatient therapy providers when the home health case is not properly and timely discharged and reported to the Medicare Common Working File (CWF). The HHA is responsible for all therapy services while a patient is in a HH episode of care. In some instances providers have been able to “collect” from a HHA, when an outpatient therapy claim is denied, but this is not the norm. While frustrating, to ensure outpatient reimbursement (and prevent recoupment), it is important to verify that the home health episode has been properly discharge and reported.

  24. Galina says:

    Can a client receive home physical therapy from home care if they just completed a two months treatment as outpatient in physician office? Are they eligeble to receive home therapy right away again? Thank you. Galina.

  25. Hello Galina. Thank you for commenting. I am not clear on what you mean by home therapy. Do you mean therapy under a home health plan of care (Part A)? Or do you mean outpatient therapy “in the home” (Part B)? All therapy must be medically necessary, whether it is Part A or Part B.

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