would be slightly affected because individuals are not encouraged to be hospitalized for such benefits, and most Medicare beneficiaries are already eligible (under part B) to receive such benefits without hospitalization. The Congress is currently considering the elimination of the homebound requirement in pending legislation for one group of Medicare beneficiaries (those with end stage renal disease) as an incentive for less costly home dialysis in lieu of center or inpatient dialysis. We believe that the elimination of this requirement for all beneficiaries requiring skilled care could well provide similar disincentives to institutionalization. Although experiments in the program are still continuing, some evidence shows that the addition of homemaker/chore services could provide disincentives to institutionalization for individuals who are greatly or extremely impaired which might help to offset the additional cost of this service. The elimination of the Medicare's skilled care requirement would substantially affect the cost and the acute care orientation of the program. CHAPTER 4 ACTIONS TAKEN ON PRIOR GAO RECOMMENDATIONS ON HOME HEALTH CARE In our report "Home Health Care Benefits Under Medicare and Medicaid" (July 9, 1974, B-164031(3)), we reported that some problems diminished the overall effectiveness of home health care benefits. Most of the problems noted in our prior report have been alleviated by the implementation of various provisions of the 1972 Amendments to the Social Security Act and by better provider understanding, gained through experience, of Medicare's home health requirements. Our prior recommendations and the actions taken on them are discussed below. UNIFORM INTERPRETATION OF EXISTING INSTRUCTION In our prior report, we found that the confusion and disagreement between intermediaries and providers in determining covered services resulted, in part, from the failure of SSA to furnish definitive guidelines. We recommended that SSA increase its effort to assure more effective and uniform interpretation of existing instructions to intermediaries and home health agencies regarding the various coverage requirements for home health services. A Home Health Coordination Committee was established early in 1974 as a part of SSA's Bureau of Health Insurance to make a full-scale review of the home health provisions under Medicare. In July 1974, the Committee started a study to determine (1) if the screening guidelines used by intermediaries to review home health claims varied greatly, (2) how intermediaries were interpreting BHI coverage guidelines, and (3) how further instructions to intermediaries and home health agencies could clarify home health benefits. A June 1976 draft report on the overall study, in part, concluded that (1) considerable variation existed in intermediaries claims review and application of Medicare coverage guidelines and (2) the use of home health care had not been unnecessarily restricted through the intermediaries claims review policies. As of September 16, 1977, no final report had been issued and Medicare officials could not agree if the study was of sufficient validity to be issued as a final report. The providers and intermediaries we visited in California felt that they no longer had a problem in interpreting Medicare regulations. The Director of the California Association for Health Services at Home, an association of home health agencies, stated that providers now understand, through experience, what "skilled nursing care" is and what type of treatment will be allowed or paid for. We visited three intermediaries and several providers in Florida and Georgia. In some instances, intermediaries and providers still disagree on the interpretation of skilled care requirements and the meaning of the intermittent nursing care, homebound, and medical necessity requirements; however, the denial of home health claims by the intermediaries was minimal. SCREENING GUIDELINES In our prior report we found the screening guidelines used by Medicare intermediaries indicated that benefits provided to program beneficiaries were different. We recommended that SSA review screening guidelines used by intermediaries and where significant differences existed, explore the feasibility of requiring intermediaries to apply more uniform screening guidelines. Medicare intermediaries were asked to submit copies of screening guidelines used to review home health claims. Thirty-two intermediaries submitted copies of their instructions. Forty-eight replied that they did not use screens in reviewing home health claims. Twenty-three of the 32 had enough common diagnoses to allow some degree of comparability. The scope of the 23 guidelines varied considerably. The screens covered from 3 to 70 diagnoses. One of the screens based the number of allowed visits on a limited number of common diagnoses and therefore were not comparable. Eight screens based the number of allowed visits on specific medical procedures. SSA believed that an adequate comparison could not be made because of an inadequate number of procedure guidelines. However, intermediaries do not use screen guidelines to deny claims. Intermediaries use them as a tool to determine if additional review by medical personnel is required. Five of the six intermediaries we visited had guidelines and screens to review home health claims. We reviewed a random sample of paid claims at each of the six intermediaries. We noted that (1) the average number of visits allowed for certain diagnosed conditions varied significantly and (2) the number of visits allowed varied from case to case. We did not determine the reasons for variance in services needed by diagnosis because a medical review of each case would be required. Intermediary officials advised us that secondary diagnosis, age and condition, and the availability of families or friends can cause a significant variance in the services needed by different people with the same primary diagnosis. ADVANCE APPROVAL PROVISION Our prior review showed that SSA had not issued regulations to implement the advance approval provision of the Social Security Amendments of 1972. We recommended that SSA establish regulations, as authorized by the advance approval provision of the Social Security Amendments of 1972, to specify limited coverage periods, according to medical condition, during which a patient would be presumed to require a covered level of post hospital home health care services. Final regulations on the presumed coverage of post hospital home health care services were published in the Federal Register on May 25, 1976. The regulations allow for voluntary use by the physician of the presumed coverage provision. In issuing the regulations, HEW stated the regulations were incomplete and needed to include a more comprehensive listing of medical conditions. Response to the earlier proposed version of the regulations included comments to the effect that certain intermediaries had already devised presumed coverage guidelines which were superior to those established. IMPLEMENTATION OF THE ADVANCE APPROVAL In our prior report we found that providers and beneficiaries were having problems with retroactive denials of claims. We recommended that SSA determine whether implementation of the advance approval and waiver of liability provisions 1/ of the 1972 Social Security Act Amendments were effective in minimizing the problem of denials and, if necessary, advise the Congress that the amendments needed modification to correct the problem. SSA's evaluation, which covered home health claims paid under interim regulations during October 1973 to September 1974, showed that the denial rate for home health agencies would have been 2.1 percent nationally without application of the waiver of liability provision. With the waiver, it was 1.5 percent. SSA statistics shows that the denial rate for home health claims has remained fairly constant between fiscal year 1973 thru 1976 ranging from 1.7 percent for fiscal year 1973 to 1.5 percent for fiscal year 1976. INFORMATION PROVIDED TO BENEFICIARIES Our previous review showed that information provided to beneficiaries on allowable home health benefits did not always clearly spell out limitations of the benefits. We recommended that SSA explore methods of further clarifying program benefits, especially the limits on the duration of benefits, to reduce confusion on the part of beneficiaries. An HEW official advised us that all beneficiary informational material was reviewed. In December 1974, SSA issued a revised Medicare handbook to all Medicare beneficiaries. We believe the new handbook could help reduce beneficiaries' confusion about benefit limitations. Two other publications, "A Brief Explanation of Medicare" and "Home Health Care Under Medicare," were also revised to eliminate beneficiary confusion concerning the duration of benefits. We found the explanations of home health benefits in these three publications to be reasonably clear and consistent. 1/Simply stated the waiver of liability provisions permit beneficiaries and/or providers to be held harmless in situations where claims are disallowed for services which are not reasonable or necessary for the diagnosis or treatment of an illness or injury, but where the beneficiaries and/or providers exercised due care and acted in good faith in receiving and/or providing the services. 25-122 O 78 pt. 2 17 |