Telehealth in home care

Part 4: Reimbursement issues for telehealth, and an important POC documentation requirement

Editor’s note: Our series of posts exploring telehealth in the home health field continues today and tomorrow with a look at what agencies need to know as they ramp up their telehealth usage, including an extra documentation requirement on the plan of care and a look at reimbursement issues.

Why won’t the Centers for Medicare and Medicaid Services (CMS) pay home health agencies for virtual visits – even during an infectious disease pandemic in which the risk of infection creates a much safer environment for patients and staff?

That’s the question frustrating many home care providers who were disappointed when the last interim final rule from CMS provided additional telehealth flexibilities but did not provide home health for virtual visits.

“The difficulty lies is the language in the regulations,” said J’non Griffin, owner and president of Home Health Solutions, a nationwide consulting and outsourcing firm for home health, hospice and long-term care.

The definition of a home health visit under 42 CFR 409.48(c) is “an episode of personal contact with the beneficiary by staff of the home health agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service.”

“Until that language is addressed, telehealth visits for home health cannot count as a visit for payment and cannot count toward the LUPA threshold,” J’non said. A LUPA is a payment adjustment made for low utlitization.

While CMS has amended some Medicare regulations on an interim basis to remove health care obstacles during the pandemic, this particular one has not yet been addressed.

“Whether and when CMS is going to allow reimbursement to agencies for telehealth hasn’t been determined,” J’non said. “But for now, it’s clear. CMS encourages agencies to make use of telehealth as part of the overall plan of care, but there will be no payment.”

Remote patient monitoring

As many agencies look for ways to mitigate COVID-19 infection risk for patients and staff, remote patient monitoring seems an attractive solution even without payment because it allows the digital collection, storage and transmission of physiological data from patient to provider.

Section 80.10 of the Medicare benefit policy manual allows remote patient monitoring for blood pressure, blood glucose levels and other indicators to be ordered as part of a home health plan of care, but the services cannot be reported as a visit without the provision of another skilled service.

“This means visits to a patient’s home for the sole purpose of setting up telehealth services or training the patient how to use the remote patient monitoring equipment are not separately billable without the provision of another skilled service,” J’non said.

“The use of technology must be related to the skilled services being furnished by the clinician,” she said.

CMS requires such remote patient monitoring to fall within the specific parameters of the plan of care – and is requiring additional documentation on the patient’s plan of care to make certain it does.

Plan of care requirement

Agencies using telehealth must include on the patient’s plan of care a description of exactly how the use of the technology is expected to help achieve the patient-specific goals outlined, J’non said.

Here’s what at 42 CFR § 409.43 (a) (3) now states about using telehealth during a public health emergency, and the POC requirement:

(3) The plan of care must include the identification of the responsible discipline(s) and the frequency and duration of all visits, as well as those items listed in § 484.60(a) of this chapter that establish the need for such services. All care provided must be in accordance with the plan of care. During a PHE, as defined in § 400.200 of this chapter, the plan of care must include any provision of remote patient monitoring or other services furnished via a telecommunications system and such services must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment. The plan of care must include a description of how the use of such technology will help to achieve the goals outlined on the plan of care.”

“This means agencies will need to avoid cookie-cutter wording in every plan of care to address how telehealth is controlling infection risks and protecting the patient from COVID-19,” J’non said.

“Be specific instead,” she said. “Show how this particular patient’s condition places him at particular risk and show how using technology is going to enable him to achieve the individual goals included on his plan of care.”

Recouping the costs

Although the use of technology cannot replace an in-home visit ordered as part of the plan of care, and remains ineligible for payment, there may be a couple of ways for home care providers to recoup at least some of the associated expenses.

CMS is allowing home health agencies to report the costs of telecommunications technology as allowable administrative and general (A&G) cost, at least on an interim basis.

And, it has announced that it will exercise enforcement discretion regarding the administration of Medicare Advantage benefit packages, allowing supplemental benefits to extend beyond normal coverage limitations.

Agencies which contract with Medicare Advantage plans may want to reach out to them to determine whether expanded benefit packages have been expanded under the public health emergency include telehealth furnished by home health agencies.

NEXT IN OUR TELEHEALTH SERIES: More telehealth pointers for agencies