Did you know that Home Health episodes and SNF (skilled nursing facility) stays that overlap your services as an outpatient physical or occupational therapy provider can keep you from being paid by Medicare?
Patients have been known to seek therapy in a private practice while residing in a skilled nursing facility. An even more common scenario is that of a patient seeking care with a therapy clinic when they are also being cared for in some capacity by a home health agency. In either of these situations, the therapy services must be provided by the nursing home or home health agency and there will be no reimbursement if a clinic bills Medicare for these services, even if the patient is not currently receiving therapy services in the nursing facility or by the home health agency.
Be sure to verify patient eligibility with Medicare before the first appointment. Most Medicare carrier IVR (Interactive Voice Response) systems and touchtone systems will allow you to access information not only for deductibles and therapy cap information, but there is usually a prompt to also check on Home Health Episodes.
A more efficient way to get the same information (as opposed to sitting on the phone trying to navigate the IVRS) is to use an online Medicare eligibility service. I personally use Cortex EDI for my Medicare eligibility checks and it has certainly expedited the entire process for me and my staff.
Important: Please bear in mind that the Medicare carrier database can only report on information that is currently in their system. If any claims have not yet been processed, that information will not be included in your eligibility check. Therefore, patient screening is a must.
A tip I learned from one Trailblazer educator in Texas who teaches therapy staff regularly at various workshops around the state: Do not simply ask your patient if he has been treated by a Home Health Agency recently. Many patients do not understand what that means. For example, if a nurse simply comes out to take their blood pressure in their home, that they fall under the care of a Home Health Agency. It would be wise to ask the patient specific questions related to what kinds of services they may be receiving in the home related to their personal care. One red flag would be if they have recently had surgery or a hospital stay. Oftentimes, these patients will be assigned care by a home health agency during their recovery period. If this turns out to be the case, be sure to contact the home health agency and ask if the patient has been discharged at this time. It would also be prudent to request a copy of the discharge documents for your records.
If it is determined that the patient is under the care of a SNF or HHA, and she still prefers to be treated by a therapist in private practice, the patient must be informed that the services are considered non-covered by Medicare. Please see my prior article entitled, Billing Medicare for Non-Covered Services for more information.