Medicare home healthcare coverage and solution for Medicare denial

Does Medicare cover home health care?

Medicare will cover home health care if
(a) your care requires intermittent or part-time skilled services, physical therapy or speech
therapy;
(b) you are confined to your home and;
(c) your doctor says you need home health care.
Once it has been determined that you are eligible for home health coverage, you can
begin to receive home health aide services in addition to skilled care. These include
(a) household services essential to your health care at home;
(b) help with medications that you would normally take yourself;
(c) simple procedures that are an extension of therapy services; and
(d) personal care including help with daily activities.


What should I look for if claim denied by Medicare?
If your Medicare coverage is restricted incorrectly, you risk losing your home health care
completely, or receiving less care than you actually need. If you are denied coverage for any of
these reasons, be suspicious and challenge the denial:

(a) Duration denials: There are no time limits on how long you can receive home health
services. If you have a chronic condition, you have a good chance of getting the coverage you need.
As long as you need skilled care at least once every 2 months, you are entitled to home health care
coverage.

During this time, you are not required to improve or reach certain goals established by your plan
of care. It is enough if your care prevents or slows your health from getting worse, or helps you stay
at your current level of functioning. This is particularly important if you are receiving skilled
rehabilitation.

(b) “Not medically reasonable” denials: Medicare intermediaries often use their own
judgment to decide if certain skilled care is medically reasonable. Your own doctor, and not an
insurance company, should decide what care you need.
The Medicare evaluator or "intermediary" should not substitute its judgment for your
doctor’s in determining what care is needed. Medicare highly values and will usually accept the
opinion of the treating physician in determining the reasonableness and need for the health
services furnished by providers.

(c) “Not homebound” denials: Medicare sometimes improperly denies coverage to
individuals who are homebound and unable to leave home to obtain necessary care. If you
cannot leave your home without help from an individual or supportive device (such as crutches
or a wheelchair), you are considered homebound.
This is also true if it is not medically advisable for you to leave your home without
assistance. You do not need to be bedridden, but should be normally unable to leave home. In
certain circumstances, you can still be considered homebound even if you attend an adult day
care program outside your home.

(d) "Family members can provide the needed care" denials: Your family is under no
obligation to give you the kind of care provided by home health agencies. Likewise, you do not
have to accept the services of a family member. In some cases, having a family member provide
the care you need is not only inappropriate but also dangerous.

(e) "No improvement" denials: Medicare coverage is available even if you are not going to
improve medically and you need skilled care to prevent or delay further deterioration or preserve
your current capabilities.

To get coverage for care that maintains your current capabilities, it should be described in terms
of reaching a goal, such as the goal of maintaining or preventing further deterioration.

(f) Supervision by a skilled practitioner: To qualify for Medicare coverage based on
supervision by a skilled practitioner, all that is required is that a registered nurse, licensed practical
nurse, physical or occupational therapist, speech pathologist or audiologist generally supervise
skilled nursing and rehabilitation services.
A supervisor does not have to be physically present or on the premises when services are
performed.

(g) Coordinating a plan of care: Medicare regulations say that your overall condition must be
considered and that skilled personnel may be necessary to perform and coordinate a series of tasks
that, taken individually, would not require a skilled professional.

(h) Observation and assessment as a skilled service: Observation and assessment are
considered to be skilled services when the skills of a technical or professional person are
required to identify and evaluate your need for additional medical procedures.
For example, a patient with congestive heart failure may need continuous close
observation to detect signs of deterioration, abnormal fluid balance or a bad reaction to
medications.
Likewise, patients discharged from a hospital while in a complicated and unstable
condition after surgery may need continued skilled monitoring to watch for post-operative
complications.

(i) Management and evaluation of care plan: Management and evaluation is a skilled
service when the skills of a technician or professional are periodically required to evaluate and
manage the home health aide services you receive. In other words, the skilled professional
oversees the unskilled services to make sure that they are effective.
For example, a nurse’s management and evaluation skills would be needed to monitor the
diet, fluid intake and other health-related needs of an Alzheimer’s patient. The services could be
provided by unskilled home health aides with the skilled nurse managing the services and
periodically evaluating the patient.

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