Patients’ eligibility to Medicare benefits is crucial to both home health and hospice agencies. Caring for eligible patients with complete and accurate documentation ultimately translates to full Medicare reimbursements. Thus, establishing patient eligibility prior admission must be done correctly. When it comes to this, it is always helpful to go back to the basics and ask — what conditions make a patient eligible for home health or hospice care?
Patients who are entitled to Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) are eligible for home health services if they meet three conditions. First, a patient must be under the care of a physician who provides services to the patient based on a regularly reviewed plan of care. Second, the physician must certify that the patient needs either intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy services. However, therapy services will only be covered if these specifically, safely, and effectively treat the patient’s condition within a reasonable frequency and amount of time. They should also be complex and can only be safely and effectively performed by qualified therapists. Third, the patient must be homebound as certified by a physician. It is important to note though that should the patient need more than part-time or intermittent skilled nursing care, he or she is not eligible for the home health benefit.
Unlike home health care, hospice care is a benefit only under the Medicare Part A (Hospital Insurance) program. For a patient to be eligible, he or she must be certified as terminally ill. This means that the patient’s life expectancy is 6 months or less. A hospice medical director or a physician member of the interdisciplinary group (IDG) and the patient’s attending physician must consider the diagnosis of the patient’s terminal condition, other related or unrelated health conditions, and current clinically relevant information supporting the diagnosis, before certifying a patient to be terminally ill. It must be noted that only a medical doctor or a doctor of osteopathy can certify or recertify a terminal illness. Only when the medical director, upon consultation with the individual’s attending physician, recommends the patient for admission, will a hospice be allowed to admit the patient.
Determining if a patient is eligible or not for the home health or hospice benefit can mitigate, reduce and eliminate claim denials and rejections for your agency. Data Soft Logic, as your Intelligent Care Partner, has developed the Billing Module, available both in Home Health and Hospice Centre to support you. The Billing Module allows agencies to check a patient’s eligibility for home health and hospice services, in just a few clicks within the system. Learn how this feature can help you maximize your revenues through efficient and accurate eligibility checks. Schedule a demo with us now to learn more.
References:
Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. 2015.
Medicare.gov. “Home Health Services Coverage.” Medicare.gov, 2019, www.medicare.gov/coverage/home-health-services.
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