The Home Health Care Team
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The TEAM consists of the Patient, the Physician, and all of the Home Health Professionals provided through the Home Health Agency such as the Nurse, PT, OT, ST, MSW, Nutritionist, and CHHA (home health aide).
A patient may require the care from one or all of these services during an episode of care. Each Skilled professional must demonstrate and document a skilled need for each visit and provide evidence of homebound status in order to meet criteria for reimbursement of services.
Just because the MD orders visits, does not make them skilled or medically necessary, and therefore not necessarily reimbursable. Under Medicare, the care must meet skilled need criteria to be reimbursed. (And the patient must be homebound for the duration of the episode of care.)
Criteria for Skilled Need
If the care does not meet the criteria for skilled need, and not meet homebound status the agency can provide this service, but the Patient will be responsible for the fees.
Additionally, there must be a skilled need for an RN, PT, OT or ST to make at least one additional visit in order to provide secondary services such as MSW and CHHA.
CHHA visits can only begin and continue so long as the CHHA is supervised by a skilled service. For instance, if an RN or Therapist will be seeing the patient for 3 weeks, and the MD orders the care, a CHHA may provide bathing services during those 3 weeks. After that time, the patient needs to pay out of pocket for the services or hire privately.
A patient may require the care from one or all of these services during an episode of care. Each Skilled professional must demonstrate and document a skilled need for each visit and provide evidence of homebound status in order to meet criteria for reimbursement of services.
Just because the MD orders visits, does not make them skilled or medically necessary, and therefore not necessarily reimbursable. Under Medicare, the care must meet skilled need criteria to be reimbursed. (And the patient must be homebound for the duration of the episode of care.)
Criteria for Skilled Need
If the care does not meet the criteria for skilled need, and not meet homebound status the agency can provide this service, but the Patient will be responsible for the fees.
Additionally, there must be a skilled need for an RN, PT, OT or ST to make at least one additional visit in order to provide secondary services such as MSW and CHHA.
CHHA visits can only begin and continue so long as the CHHA is supervised by a skilled service. For instance, if an RN or Therapist will be seeing the patient for 3 weeks, and the MD orders the care, a CHHA may provide bathing services during those 3 weeks. After that time, the patient needs to pay out of pocket for the services or hire privately.
The MSW may not continue if the RN or (any) Therapist is no longer seeing the patient, but can certainly offer consultation over the phone. Payment for the MSW's time for these services should be negotiated with administrative staff prior to making such phone calls.
Once the patient is no longer homebound, all medical services will have to be provided from an outpatient setting. (Remember...Just because the patient doesn't have transportation, does NOT make the patient homebound and cannot justify continuing home health services.)
NOTE: Some private insurances and Medicaid (in some states) do not have a homebound requirement, but Medicare does. Some private insurance criteria is also somewhat less stringent in defining the skilled need. Refer to the pay source for specific information about reimbursement. Many insurance companies require prior authorization for all visits and without this can withhold payment for services.
NOTE: due to changes passed during the COVID-19 EHR, OT is no longer considered a secondary service. They are now a primary service and can perform the SOC and supervise the CHHA.
Once the patient is no longer homebound, all medical services will have to be provided from an outpatient setting. (Remember...Just because the patient doesn't have transportation, does NOT make the patient homebound and cannot justify continuing home health services.)
NOTE: Some private insurances and Medicaid (in some states) do not have a homebound requirement, but Medicare does. Some private insurance criteria is also somewhat less stringent in defining the skilled need. Refer to the pay source for specific information about reimbursement. Many insurance companies require prior authorization for all visits and without this can withhold payment for services.
NOTE: due to changes passed during the COVID-19 EHR, OT is no longer considered a secondary service. They are now a primary service and can perform the SOC and supervise the CHHA.
