Signs Point to Non-Physician Home Health Certification Initially Happening Under Medicare Advantage

A bill that would eliminate Medicare’s physician-certification policy has drawn industry-wide support. But the Centers for Medicare & Medicaid Services (CMS) may first opt to test non-physician certification through Medicare Advantage (MA) in lieu of traditional Medicare.

The Home Health Care Planning Improvement Act of 2019 — H.R. 2150 — was introduced in April. If passed, the bill would broaden the scope of who is allowed to certify the need for home health services under Medicare rules.

Specifically, the legislation aims to allow nurse practitioners, physician assistants and other advanced practice nurses to certify home health care services. Under the current Medicare rules, only physicians are able to order home health services and certify — and re-certify — individuals as meeting eligibility requirements for the home health benefit.

Generally, many home health providers have criticized that stringent process as archaic and burdensome. Further compounding matters, the process often leads to costly delays when physicians are not readily available.

“This bill modernizes the Medicare home health benefit,” Bill Dombi, president of the National Association for Home Care & Hospice (NAHC), told Home Health Care News. “When this legislation is passed — I’m not saying if — it will make life a lot simpler, more efficient and more consistent for the home health agencies, as well as the patient. They will be dealing with the person that is caring for the patient rather than a physician who may not even know the patient.”

The legislation has garnered widespread support throughout the industry as a potential game-changer, especially with the Patient-Driven Groupings Model (PDGM) and a phaseout of Requests for Anticipated Payment (RAPs) just around the corner.

“When the home health revenue cycle blows up because of the RAP money going away and physicians orders are sitting on their desks, not being signed, Medicare is not going to be paying home health agencies [as they wait around]” Peter Miska, owner and president of Phoenix Home Care, told HHCN.

Burr Ridge, Illinois-based Phoenix Home Care is a home health provider that serves the state’s Cook, DuPage, Grundy, Kane, Kendall, Lake, McHenry and Will counties.

Currently, RAPs provide upfront financing of up to 60% of the anticipated payment for a home health episode. CMS is eliminating them fully in 2021.

The Home Health Care Planning Improvement Act of 2019 is far from the first version of this type of non-physician certification bill.

Efforts to broaden the scope of who is allowed to certify for home health under Medicare have been underway for at least seven years, according to Dombi.

“The bill is still gathering co-sponsors,” he said. “It has life, but its lifespan is limited in two ways: One, legislation often has to be reintroduced into Congress. The other aspect is whether Congress takes time to legislate.”

The biggest obstacle for this legislation over the years has been the Congressional Budget Office (CBO) failing to come up with an assessment as to whether the bill has any cost attendant to it, Dombi said.

As of mid-November, the bill had 120 co-sponsors. There is also a companion bill in the U.S. Senate.

Though the legislation has significant support, it’s currently getting lost in the Congressional shuffle, according to Dave Totaro, chief government affairs officer at Bayada Home Health Care.

“We believe it has what it needs to pass,” Totaro told HHCN. “It hasn’t been brought to the floor because it’s one of the probably hundreds of bills that are just not moving in this Congress because of other issues, such as impeachment proceedings. In many ways, it’s a lame-duck Congress.”

Moorestown, New Jersey-based Bayada provides home-based nursing, rehabilitative, therapeutic, hospice and assistive care services across nearly two dozen U.S. states, with additional locations in Germany, India, Ireland, New Zealand and South Korea. With 1.27% market share, the provider was recently ranked as the seventh-largest home health provider in the U.S.

Since the non-physician certification bill’s introduction in the spring, one new aspect that has arisen is the idea that CMS may test out the concept through Medicare Advantage.

“Already, Medicare has approved a demonstration program to do this within the Medicare program in Maryland because that state is an all-payer system using Medicare standards,” Dombi said. “Beyond that, the executive order issued by the White House recently references getting non-physician practitioners to practice at the top of their credentials, which we read to be supportive of this kind of move.”

In October, President Trump signed an executive order that aims to “protect and improve” Medicare.

Additionally, Dombi notes that the current administration has shown a propensity for making innovative moves within MA versus the traditional fee-for-service program.

NAHC would be reluctant to throw support behind an MA-only test of non-physician certifications.

“We have always thought that having different standards for eligibility between Medicare Advantage and the traditional Medicare program is not the best way to go,” Dombi said. “A third of Medicare enrollees are on MA plans, so doing something that disadvantages two-thirds of Medicare enrollees just doesn’t make sense.”