More Telehealth, Less Red Tape: What Agencies Should Know About CMS’s Home Health Changes

The U.S. Centers for Medicare and Medicaid Services (CMS) took “unprecedented” action to reduce red tape for home health care agencies and other Medicare providers on Monday.

Although the changes are, in theory, temporary, many home health stakeholders welcomed the newfound flexibility aimed at the COVID-19 pandemic. Some, however, were left scratching their heads, confused about what the changes actually mean for them.

Among the updates: a suspension of the Review Choice Demonstration (RCD), additional leeway around the homebound requirement, the waiving of in-person nurse supervisory rules and additional telehealth opportunities.

The telehealth point, in particular, has been the most puzzling.

National Association for Home Care & Hospice (NAHC) President William A. Dombi expressed appreciation for the CMS changes in a Tuesday statement, but emphasized that more work needs to be done.

While hospitals are skilled nursing facilities (SNFs) are in the spotlight now, attention will soon turn to the nation’s home health care industry, which, in coming days, will be tasked with caring for a sudden influx of discharged COVID-19 patients.

“Our thanks go out to CMS for taking this big step forward,” Dombi said. “While there remains work to be done, this is progress at such an important time. Additional changes are still needed, particularly around direct reimbursement for telehealth services as home health agencies cannot afford to provide the care for free.”

There’s no question that Monday’s announcement from CMS changed the home health care world for the time being. The question is: to what extent?

Is CMS loosening homebound requirements? Yes.

CMS has updated homebound requirements to better meet the needs of patients during the COVID-19 crisis

Previously, homebound patients were considered such if they needed the help of another person or medical equipment to leave their home, or if their doctor believed their illness could worsen if they left their home. Additionally, patients have traditionally been considered homebound if it is generally difficult for them to leave their homes all together.

Now, if a physician determines that a patient should not leave the home because he or she either has the coronavirus or could be especially susceptible to its effects, then that person can also be considered homebound — and, thus, qualify for the home health benefit.

“If the doctor says that the beneficiary isn’t to leave home because of either confirmed or suspected COVID-19, or the patient’s got a condition that makes them more susceptible, then they’re considered homebound,” Aaron Tripp, the VP for reimbursement and financing policy at LeadingAge, told Home Health Care News. “So that loosens [things] a little bit.”

Washington, D.C.-based LeadingAge is an association representing over 5,000 nonprofit providers of aging services.

This is a positive development for agencies because it widens the scope of patients who can receive care in the home.

Is CMS paying for telehealth visits? No.

But they are offering potential avenues for agencies to receive reimbursement for telehealth services in some circumstances.

Therefore, the updates were a step in the right direction, Tripp said.

“The simple answer is, ‘Yes’,” Tripp said, in response to whether the updates move the needle for telehealth in home health. “But the magnitude of that needle move is probably small.”

CMS says it is statutorily prohibited from paying for remote visits in substitution for in-person visits, according to the agency, which offered clarity on Tuesday during a call with providers.

Still, CMS is potentially allowing agencies to contract with a physician to provide telehealth services to patients. That way, a physician could bill for the telehealth service and possibly pay a contracted rate to the agency.

Any telehealth visits still need to be physician-ordered. In other words, agencies don’t have the autonomy to decide when a patient can be treated through a telehealth visit in lieu of a face-to-face one.

“[CMS] is saying that for the duration of the public health emergency, they’re going to — on an interim basis — allow telecommunication to be used in conjunction with the provision of in- person visits,” Tripp said. “So they’re opening the window, but it feels like it’s probably more a crack than really opening it. Because they’re still saying that technology does not count as one of your home health visits.”

If a patient were to contract the coronavirus, the plan of care could be adjusted to lean more heavily on telehealth visits over in-person ones. But while that adjustment is allowed, those remote visits would not count towards in-person visits as it relates to reimbursement, Tripp said.

A lack of in-person visits will still trigger a low utilization payment adjustment (LUPA). But once that LUPA threshold is met, then agencies have the freedom to conduct more remote visits.

Is CMS suspending RCD? Kind of.

For agencies in states that have implemented or are currently implementing RCD, the requirements that come with it have also been temporarily suspended. So far, RCD is live in Illinois, Ohio and Texas; it’s eventually scheduled to roll out in North Carolina and Florida later this year.

RCD aims to reduce improper billing and prevent fraud. Broadly, it requires home health providers to show compliance with Medicare rules through either pre-claim or post-review processes.

“Claims for home health services furnished on or after March 29, 2020, and before the end of the public health emergency (PHE) for the COVID-19 pandemic in these states will not be subject to the review choices made by the home health agency under the demonstration,” a CMS statement read.

In alignment with many of CMS’s moves in March, the RCD suspension is allowing agencies to focus more on critical matters and less on paperwork. The pause is optional for home health agencies in RCD states.

“It’s helpful,” Tripp said. “In some ways, they’re leaving a door open. It says that providers have the option to pause their participation in an RCD. I can’t imagine that there are any home health agencies that say, ‘No, please let me continue doing that,’ in the midst of this, but the language gives the home health agencies in those states that are affected the choice to pause.”

It’s true that the optional RCD pause will give providers a temporary break from the additional legwork that comes with it.

But perhaps that’s not the best thing for agencies in the long run, Sara Ratcliffe, the executive director of Illinois HomeCare & Hospice (IHHC), told HHCN.

“For states already on RCD, the pause is more like a delay,” Ratcliffe said. “For agencies on pre-claim review, if they choose to pause during the public health emergency (PHE), the claims they submit during the pause will be subject to 100% post-payment review following the end of the PHE. This means they will receive additional development requests (ADRs) on 100% of claims submitted during the pause.”

Broadly, that means a lot more work down the road to respond to ADRs on every claim submitted during the pause, she said.

“For those on post-payment review or the 5% spot check, they will receive no ADRs during the PHE, but those ADRs will be held and then sent after the PHE ends,” Ratcliffe added. “This means that the ADRs will just pile up during the pause.”

Similar to the telehealth updates, IHHC is hoping that CMS will go a step further when it comes to the RCD changes.

“Our hope is that CMS will re-consider what happens after the PHE ends to lessen the burden for providers,” Ratcliffe said.

Is CMS waiving in-person supervisory requirements? Yes.

On-site supervisory nurse visits have also been ruled temporarily optional. However, CMS is still encouraging remote supervision for the time being.

Normally, a nurse supervisory visit every two weeks is required. But with the entire nation social distancing as a means to reduce the spread of the coronavirus, CMS is looking to avoid person-to-person contact when it’s not necessary