Are you leaving money on the table?

April 21, 2006

Many doctors are afraid to bill Medicare for home healthcare certification. But if you follow the rules, you will get paid.

Internist Jeffrey M. Kagan of Newington, CT, bills Medicare for something that few other doctors charge for: certification and recertification of patients' need for home healthcare. "They add up," he points out. "If you have six patients who are going to be seeing the visiting nurse for a year, you've got to do six on each of them, so that's 36 times. For doing those certifications, you can make $2,000, and it's found money." Kagan and his partner do even better than that: They sign off on 60-day care plans for homebound patients about 120 times a year.

Yet only about 10 to 25 percent of physicians are charging to certify or recertify someone for home care, says internist Peter A. Boling, professor of medicine at Virginia Commonwealth University School of Medicine in Richmond, VA. "Most doctors don't understand the billing options," notes Boling, who's also a former president of the American Academy of Home Care Physicians. He rejects the arguments of some physicians that the paperwork is too burdensome. Kagan agrees that it's no big deal, once staffers learn how to do it.

However, interviews with several physicians suggest (and an HHS Office of Inspector General report confirms) that many doctors are afraid of being audited if they fail to conform to the tricky Medicare rules on home care. If they don't bill for certification, they believe, they're lowering their risk.

If you, too, are leaving money on the table because you're afraid of violating Medicare regulations, read on. There's less to fear than you think; and if you follow the rules, you could be earning more and providing better care for your patients.

The fear factor is overrated

In 1999, the Office of Inspector General published a "special fraud alert" on home healthcare that made many doctors leery of this area. The OIG warned that "physician laxity in reviewing and completing [home health] certifications" was facilitating fraud and abuse in the industry. It also warned doctors that they could be liable for criminal and civil penalties if they failed to determine the medical necessity of home care. But the alert also said they wouldn't be punished for mistakes or "simple negligence." And in its report three years later, the OIG emphasized that doctors can be held liable only if they "knowingly sign false or misleading certifications."

There have been a few well-publicized prosecutions of doctors in connection with home care fraud. For example, in 2002, a federal court in Missouri found FP Jan Dierks Garwood guilty of conspiracy to defraud Medicare. The suit charged that he accepted kickbacks in exchange for home health referrals and falsely certified that patients were homebound. But healthcare attorneys say the government hasn't taken legal action against physicians for making honest mistakes in home care certification or care plan oversight.

David M. Glaser, a Minneapolis attorney who specializes in Medicare audits, notes that the doctors who should pay the closest attention to the regulations are those who have a financial relationship with an agency. The Stark rules allow you to refer patients to an agency that employs you as a medical director, he points out, but financial ties with a home care firm may create problems if questions ever arise about your referrals.

If a physician submits home health claims "recklessly" on a regular basis without doing any supervision, he could face penalties, says Lester J. Perling, an attorney with Broad and Cassel in Fort Lauderdale. "But if a doctor occasionally orders home healthcare, and once in a while he's loose or sloppy with the criteria, that's not going to get him in trouble." The worst that could happen, he says, is that he might have to return some Medicare payments.