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Health Dollars & Sense

Crackdown on Care at Home

April 12, 1999|BOB ROSENBLATT

It's a lot harder these days to get Medicare to pay your home care bills.

This was the fastest-growing part of the giant federal health care system. A nurse would visit a diabetic's home to give her a daily insulin injection. A stroke victim would have visits at his apartment from a speech therapist, and a homemaker aide would help him bathe.

Congress hit the brakes hard in 1997, concerned about soaring costs and widespread reports of industry fraud. The head of one of the biggest home health care organizations went to prison for bilking taxpayers of millions of dollars for services never delivered.

The crackdown by Congress is having another troubling effect: It's made it much more difficult for many people to get benefits due to a new, much-stricter payment system. In the past, the patient's doctor and the health care organization decided how long treatment would last, and then billed the government. Under the new rules, the government sets a limit on how much the organization can bill the government for treatments.

A home health care agency budget is now linked to its average annual spending per case. For example, if an agency spent an average of $3,000 a year in the past, and gets 100 cases this year, the total payments from Medicare for the agency will be $3 million. The new rules, which began last year, provide a system for slowing down the growth of spending, but also deliver a powerful incentive to avoid the costly cases, the ones that might run into thousands of dollars a year.

"It's a terrible situation for seniors; there is a huge crackdown on home care agencies," said Jamie Court, director of Consumers for Quality Care, a Santa Monica-based advocacy group. His 96-year-old grandmother, who was injured in a car accident and couldn't lift her arms above her shoulders, had her benefits terminated when the agency declared her condition was stable and didn't require further visits. Luckily, she is able to pay for the physical therapy and homemaker aides with her own money.

Others without sufficient funds may not be as fortunate. There is a "no-care zone" developing, said Joe Hafkenschiel, president of the California Assn. for Health Services at Home, a trade group.

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For Medicare beneficiaries--people age 65 and over, and the disabled of all ages--who need home care, this is a time to be particularly vigilant, to know all your rights under Medicare and to exercise them with determination.

You qualify for health care at home if a physician certifies that you need skilled care on an intermittent basis. And you must be homebound, unable to get to the doctor's office on your own. The benefit includes "nursing care, physical therapy, speech language pathology services, home health aide services, durable medical equipment (such as wheelchairs, hospital beds, oxygen and walkers) and supplies," according to the government guide "Medicare and You." The services are free, but you pay 20% of the Medicare-approved charges for the equipment. The services must be provided by an agency approved by Medicare.

Under the old system, there were astonishing variations in the use of the program, depending on local doctors and the particular insurance companies handling the processing of claims for the geographic area. Nationally, the average beneficiary using home care--about 10% of the Medicare population in a given year--received 74 visits in a year. But the number was as low as 35 in Oregon and as high as 160 in Louisiana. For reasons unknown, the South was the best place to get home care, with average visits of 121 a year in Alabama, 113 in Tennessee and 130 in Texas. California's figure was 51, according to a report compiled by the American Assn. of Retired Persons.

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The new system, tied to past spending by an agency, is much more circumscribed. One key tip: If you anticipate a long and difficult recovery, look for an agency with high average spending, greater than the typical $3,000 cost per case. Ask the agency what its average cost per case was last year.

"Sometimes you can use the physician to leverage the home health agency," said Aileen Harper, head of direct services for the Center for Health Care Rights, a Los Angeles-based Medicare advocacy organization. "You need the strong support of the physician." Make sure the doctor prepares a detailed treatment plan, with extensive details about the patient's problems and the kinds of treatment and assistance she needs, and her inability to manage on her own or travel outside the home for treatment, says Harper.

If the home health agency decides to terminate treatments, you are entitled to a written notice of non-coverage. Many firms don't bother notifying patients, simply telling them that Medicare will no longer pay for their care. That is a violation of Medicare rules, said Harper.

Insist on the written notice, and tell the agency you want to file a Medicare claim even if the home health agency doesn't think you meet Medicare guidelines.

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