Home Health Agency Transfer Policy

Table of Content

• AMA Disclaimer of Warranties and Liabilities.
• New CoPs for discharge
• L&C Policy and Procedure Manual - Home Health Forms
• Discharge, Transfer and Referral Policy
• HOME HEALTH CARE SOLUTIONS, LLC. Transfer and …
• Home Health Care Policies: Potential New Discharge Planning Rules
• CMS just changed the rules for discharge planning -- and star ratings may matter more

The pertinent OASIS form will be completed at this time by the licensed professional initiating this change. If a patient requires post-acute care in a SNF, IRF, LTCH or IPF during the 30-day period of home health care, CMS expects and recommends your home health agency discharge the patient by completing the RFA-7. Your agency must readmit the patient with a new start-of-care assessment upon return to home care.

The Centers for Medicare and Medicaid Services wants facilities and agencies to use that information about patient goals and help patients check out provider performance data to better match patients with the next health care setting. Home health agencies may discharge beneficiaries before the 60-day/30-day period of care - episode has closed if all treatment goals of the plan of care have been met. The situation may occur when a beneficiary is discharged and returns to the same home health agency within a 60-day episode/30-day period of care. But the new discharge planning rule revises certain sections of the CoPs to add specific new requirements about including patient goals and preferences, and considering those patient goals when assisting patients during the transition to a different health care setting.

AMA Disclaimer of Warranties and Liabilities.

The discharge is necessary for the patient’s welfare because the HHA and the physician who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities. Discharge planning will be begin when you are admitted to the agency based on the findings of the comprehensive assessment performed at admission. You and/or your representative will receive education and training to facilitate a timely discharge. When a beneficiary is discharged and readmitted within the same 60-day episode/30-day period of care, the HHA will need to complete a new Outcome & Assessment Information Set , plan of care , RAP, and final claim (or NO-RAP LUPA in lieu of RAP and final claim).

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New CoPs for discharge

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You may be more aware of the option to discharge versus not discharge, but like most home health agencies, you continue to be challenged with actually making that decision. It would be easier if there was a hard-and-fast rule, and you wouldn’t have to think about it. To avoid billing errors in a transfer situation, the receiving agency must enter a condition code (FL 18-28) "47" on the first RAP and claim that is billed for the beneficiary after the transfer is completed. When a beneficiary decides to transfer to another HHA, refer to the following information, depending upon whether you are the transferring or receiving agency. 3.If the patient’s insurance changes to an HMO or PPO that refuses to allow our agency to continue to provide services to the patient.

L&C Policy and Procedure Manual - Home Health Forms

The receiving home health agency now becomes the "primary" agency and assumes the responsibility to notify the beneficiary that all services under the HHA's plan of care need to be provided by the primary agency . Access the Medicare beneficiary eligibility system to determine whether the patient is under an established home health plan of care. See the CGS Checking Beneficiary Eligibility web page for more information about the systems available to providers to check Medicare beneficiary eligibility information. If you elected to transfer from another agency and were under an established plan of care, Medicare requires us to coordinate the transfer. The initial home health agency will no longer receive Medicare payment on your behalf and will no longer provide you with Medicare covered services after the date of your elected transfer to you agency. “This means home health agencies will need to work with patients and their caregivers to select a good match in a post-acute care provider by using and sharing data that includes quality measures and resource use measures,” J’non said.

Medicare's newest rules may prompt home care providers to work a little harder on their performance ratings to boost referrals this winter. According to a question posed to CMS, many home health agencies commonly complete a transfer and then ROC for patients transferred to any inpatient setting, unless they are not expected to need further home care. The questioner wanted guidance about how to answer M0100 (Reason for assessment ). HHAs will receive a partial episode payment for the first episode to reflect the shortened period of care prior to the beneficiary's discharge. The next 60-day episode/30-day period of care begins the date of the first billable visit under the readmission.

Any questions pertaining to the license or use of the CPT must be addressed to the AMA. The patient must be given 2 days written and verbal notice that the agency is unable to provide services without a source of reimbursement. A Notice of Medicare Non-Coverage must be completed giving the patient the options available.

6.The patient and his or her family is not compliant with the Plan of Care, thus creating an environment in which the agency is unable to provide services. The patient and will be an active participant, when possible, in planning for his / her transfer, referral or discharge from the agency. If you need more information about our wind forecast for Gunzenhausen, have a look at our help section. Beneficiary's name; Beneficiary's Medicare ID number; Name of home health staff person who was contacted; and The date and time of the contact.

The patient is admitted to post-acute facility such as in-patient rehab, transitional care or a skilled nursing facility. Patients in need of continuing care at the time of discharge will receive written and verbal instruction regarding any resources available to meet their needs. The patient and / or their legal representative will be informed in a timely manner of impending transfer within a reasonable time frame prior to the actual event.

The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. Starting Nov. 29, the discharge process at facilities and home health agencies must focus on the patient’s goals and treatment preferences, with specific documentation required.

You will be given advance notice of your discharge or transfer to another agency in accordance with applicable state regulations, except in the case of an emergency. All discharges or transfers will be documented in your medical record. You will receive an updated list of your current medications along with any instructions needed for ongoing care or treatment. We will coordinate referrals to available community resources as needed. New Conditions of Participation are being revised to make sure information about treatment goals will follow a patient between health care settings -- from facilities to home health and then on to any other post-acute care setting when the patient is discharged from home care. Document the beneficiary was informed that the original home health agency will no longer receive Medicare payment and will no longer provide Medicare covered services to them after the transfer is effective.