Foreword

The 1980s were a time of great upheaval in home care, when agencies were being subjected to intense scrutiny that arose from the growing awareness of the need to protect the elderly, concerns about higher Medicare expenditures, and the rapid growth in the number of home health agencies in the United States. In response to these trends, Congress commissioned a study titled the “Black Box of Home Care Quality” in an effort to assess the state of affairs and develop recommendations to address the identified problems. The findings of this study resulted in reproach of home care providers and those responsible for their oversight. At the same time, many home health agencies found themselves in financial distress because Medicare contractors retroactively denied payment for large numbers of claims for services that had been appropriately delivered. This phenomena was known as the “denial crisis of the 1980s.” It was during that time of confusion and consternation that I first met Tina Marrelli. We were colleagues, both working for home health agencies and serving together on the board of directors for the Maryland Association for Home Care.

One thing that was very clear to Tina and me in those days was that there was a severe shortage of guidance about the Medicare home health benefit including who qualified for home health services, what clinical services were covered by Medicare, and how services should be documented. Medicare instructions about home health were limited, vague, and loosely interpreted by contractors as well as providers. Since compliance was impossible without direction, the home health community’s oft-repeated retort to payment denials was “tell us what we need to do, and we will do it.” These pleas for clarity were eventually answered after the home care industry filed, and won, the landmark Medicare class action lawsuit, Duggan v. Bowen. As a result, the court directed Medicare to rewrite the home health benefit and to develop detailed policy descriptions for providers and contractors.

Although Tina and I went our separate ways in the early 1990s, we worked in parallel spheres where we both continued to pursue the goal of ensuring that proper policies were created and disseminated to home health agencies so that incorporation of the policies into agency practices was both reasonable and feasible. Armed with the belief that change at the source was also needed, Tina first worked as a senior policy analyst, and later acting branch chief, at what is known today as the Centers for Medicare & Medicaid Services (CMS). In those positions, she had a lead role in developing the policy guidelines for the home health benefit, ensuring that the Medicare contractors adopted them, and substantiating that proper payments were made. She played an active role in teaching the Medicare payment contractors about the coverage nuances in the updated Medicare manuals that were promulgated as a result of the lawsuit.

Since then, as consultant and author who still makes home visits, Tina has focused her attention on bolstering home health agencies’ capacity to legitimately secure Medicare payment by serving as a guiding light for compliance. Meanwhile, I had moved on to become vice president of regulatory affairs at the National Association for Home Care & Hospice. There, and in my subsequent work as a consultant, I, too, have been able to support and help sustain the delivery of much needed services to patients by providing interpretation of regulations and policies to home health agencies through counseling, writing, and educational programs. Today, both Tina and I remain committed to assisting the home health community by providing the information needed to ensure compliance.

More than 30 years have passed since the “denial crisis of the 1980s,” yet many of the issues of then are the issues of now. The elderly population continues to grow, as do concerns about Medicare expenditures, and a resurgence of growth in the number of new home health agencies. Denial of payment for services provided is again increasing. Control of fraud and abuse is the hot topic when Medicare expenditures are discussed.

When noncompliance is identified, there is no differentiation made by Medicare contractors and government oversight agencies between ignorance of the rules and outright fraud. Fulfillment of the many, ever-changing Medicare requirements is especially problematic in home health. Here, unlike in other healthcare settings, nurses and therapists are alone in the home, acting as sole decision-makers in determining patient needs and whether they qualify for Medicare payment. Therefore, it is critical that direct care workers are armed with the information needed to ensure compliance.

Home Care Nursing: Surviving in an Ever-Changing Care Environment will serve as a valuable tool to health care educators, home health managers, and orientation and in-service personnel to fulfill these needs. It delivers in-depth information in a manner than can be easily understood and applied by everyone who needs to be in the know. When it comes to knowledge of the Medicare home care benefit, ignorance is not bliss, nor is it an acceptable excuse for non-compliance. Tina Marrelli’s new book dispels regulatory ignorance and provides the information necessary for solid decision making.