Non-Physician Certification in Home Health Care Blocked by State-Level Barriers

Over the past several years, it seems as though the home health industry has been inching closer and closer toward the elimination of Medicare’s strict physician-certification policy. Now — thanks to the CARES Act — nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs) are able to certify eligibility for home health.

While Congress paved the way for non-physician certification in March with support from the Centers for Medicare & Medicaid Services (CMS), a closer inspection reveals that states ultimately have the final say when it comes to this matter.

Home health industry insiders have long been vocal about Medicare’s physician-certification policy — a rule many see as antiquated and overly rigid. Generally, those critics argue the policy created roadblocks that made it more difficult for older adults to gain access to home health care, in turn impacting providers’ bottom lines.

Before the CARES Act, home health services had to be certified — and recertified — by a physician. That process often resulted in heavy delays, especially when physicians were busy.

PAs, in particular, are fairly autonomous in terms of their ability to practice. They are often not in the same location as the physician with whom they collaborate or work with, according to Michael Powe, vice president of reimbursement and professional advocacy at the American Academy of PAs (AAPA).

“For that reason, it’s important for PAs to have the ability to take care of the complete range of services their patients need,” Powe said. “If you’re a PA in a satellite clinic, that might be 25 miles away from the collaborating physician. You don’t want to have to run to that physician to have them sign-off on a certification for home health.”

AAPA is an Alexandria, Virginia-based nonprofit advocacy organization that represents more than 131,000 PAs across the U.S.

When patients aren’t able to get home health care services in a timely manner, those delays drive up costs and result in negative health outcomes.

“They may be in another situation, such as being in a hospital for an extra day or two if can’t get the home health services they need,” Powe said. “That simply runs up the cost of health care for the entire system. If those [home health services] aren’t being provided in a timely manner, then you’re more likely to have a patient who suffers an adverse medical consequence.”

The CARES Act was an attempt to course correct and avoid those issues. It pulled from the April 2019 Home Health Care Planning Improvement Act, which previously sought to give NPs, PAs and CNSs the ability to certify home health permanently.

“It makes it a much more manageable relationship between the home health agency and the attending practitioner for the patient,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “Everything from the original plan of care, to changing orders, to signing the documents on a timely basis in order to then submit and get payment — it really reduces some administrative and care roadblocks.”

Despite federal regulations, there are a number of state-level challenges that stand in the way for NPs, PAs and CNAs.

For example, the scope of practice for NPs is an issue in some states. NPs are divided into two classes: independent practice and collaborative practice with a physician. Less than half of states allow for full, independent practice, according to Dombi.

Meanwhile, most states require PAs to work under the supervision of a physician. PAs are allowed to take on the tasks of ordering care and certifying eligibility, provided that supervisory status exists.

Another issue comes by way of licensure in the states, according to Dombi.

“[About] 35 states have full-blown licensure for home health agencies,” he said. “That licensure generally is fashioned consistent with the Medicare Conditions of Participation (CoPs). While the [CoPs] for Medicare have changed, states have to take the step of changing and updating their own licensure standards to mirror those.”

Another challenge comes from the Medicaid side. There are many states where the Medicaid payment rules need to be updated to allow for a practitioner — and not just a physician — to authorize plans of care and certify eligibility.

Dombi pointed out that the issues surrounding Medicaid payment rules and state CoPs likely have more to do with timing, meaning state governments may just be slow to catch up with federal changes, than a difference of opinion in regard to policy.

On the flip side, Dombi stresses that the scope of practice issues are more serious.

“Some states may never allow non-physician practitioners to have independent practice, and that’s within the state authority to do so,” he said.

As things stand, larger providers that run multi-state operations will have the major task of figuring out the rules and regulations in each state.

“They definitely carry a lot of risks, if they think that a non-physician practitioner can do everything in all of the states,” Dombi said. “Having to manage that on a state-by-state basis creates a burden, of sorts, for them. If you’re in a single state, as a small company, find out what the rules are — and follow them.”

Moving ahead, Dombi believes advocacy will continue to be important to help get state policies to catch up with federal law.

“We’ve worked with many of the state home care associations, which are taking the step to do that,” he said. “Those voices within home health care and the non-physician practitioner community have to step up … and initiate the advocacy to make that happen.”

Overall, 30 states have recently taken temporary or permanent actions to authorize NPs to order home health services. In the last week alone, both California and New Mexico updated their regulations to permanently authorize NPs to order home health services, according to the American Association of Nurse Practitioners (AANP).

Austin, Texas-based AANP is a national advocacy organization that represents the interests of more than 270,000 NPs.

So far, NAHC has worked with state associations in Massachusetts, New York and California, according to Dombi.

Additionally, organizations such as NAHC, AAPA, the American Academy of Home Care Medicine, LeadingAge, Visiting Nurses Association of America and others collaborated on a letter addressed to the National Governors Association, encouraging policymakers to recognize the federal change and provide flexibility.