Home Health Care (Medicare)
Definition of Home Health Care
"the provision of services and equipment to the patient in the home for the purpose ofrestoring and maintaining his or her maximal level of comfort, function, and health"
What are Diagnosis Related Groups (DRGs)?
TEFRA Act in 1980's took every diagnosis used and assigned a number to it. Then set an average length of stay in hospital with allowable charges
Who defined "Home Health Care"
The Council on Scientific Affairs in 1990
Who developes Medicares guidelines and standards?
They are developed by the Department of Health Care Financing Administration (HCFA)
How many parts does Medicare have?
Two parts A and B
What is allowable Medicare charges?
For every procedure, DRG, or piece of medical equipment there is an allowable Medicare charge but it must follow Meidicare Guidelines. If billed directly they must "accept" Medicare allowable current charge
What is Medicare Part A?
Hospital Insurance
How does Medicare Part A work?
Reimbursement=100% of ASSIGNED AMOUNT! Utilites intermediary: Insurance company (Blue Cross) Paid by government or management company of Medicare for government
What is the most common microbe found in homecare?
pseudomonas
What is Medicaid?
A state and federal program that will pay most health care costs for people with limited income and assets. Eligibility varies state to state
What is Medicare Part B (Suppliers)?
Coverage----Only pays 80% of: Physician services (office visits)--Outpatient hospital care---Home Health Care Services (durable Medical Equipment (DME) and (Unit dose medication programs)
What does Medicare Part A cover?
1) inpatient hospital care 2) skilled nursing facilities 3) Home Nursing Agencies 4) Hospice Care
What is medicare?
1. Government program for people 65 yrs or older Also, 2. some people with disabilities under the age of 65. Also, 3. People with end-stage Renal Disease (permanent kidney failure requiring dialysis or transplant
How is Home Health Care best provided?
1. When in the patients best interest 2. The patient is willing, cooperative, and/or capable of receiving or performing the prescribed care or procedure and adequate family and/or professional support exists for the family
What is assignment vs non-assignment?
Assignment bills Medicare directly whereas Non-assignment bills patient then patient must contact insurance
What are HCFA's responsibilites?
Defining general items & procedures covered by Medicare. ***Developing standards for reimbursement base on "Medical Necessity" (Diagnosis related DRG's (Diagnosis Related Groups)
What is an example of a DRG?
Emphysema = DRG #11----> LOS= 4 days---Medicare allowable=$4000
What happens if patient is discharged and re-admitted withing 7 days with the same diagnosis?
Insurance will not pay
What is medicare?
Is federally "governed" by the Department of Health and Human Services
How is insurance/reimbursement applied in home health care?
It is built into rental of equipment
How do I get Medicare Part A?
Most people get Part A automatically when they turn 65. (Medicare taxes paid while working pays for it)
Do people have to pay for Medicare Part A?
No
Should you ever promise coverage to patients?
No
Will Medicaid pay for all nursing homes?
No, only nursing home care provided in a facility certified by the government to provide services to Mdicaid recipients
What is Medicare Part B?
Optional, pay a monthy premium- covers Home Care, prostetics,etc
What is FICA?
Part of medicare and social security
How does Medicare Part B reimburse?
Patient pays monthly premium (may be higher payment if not enrolled at 65). Covers 80% of ASSIGNED amount. Supplies MUST bill remaining 20%
Assignment vs Non-Assignment example
charge for oxygen=$430----> Medicare allowable $326----->80% of allowable = $260----> MUST bill patient or secondary insurance for remaining 20%