by Johnathan Eaves, Senior Director of Communications, Axxess

Treating Medicare patients comes with a level of nuance that is important to understand to ensure that organizations remain compliant and patients receive appropriate care. Standards for quality care and payment can sometimes be dictated by Medicare’s payment policies and at other times be decided by the Conditions of Participation. There is an important difference between these two governing principles that providers should understand to ensure compliance.

Care at home industry veteran and Axxess Senior Vice President of Clinical Services Arlene Maxim RN, HCS-C, offered insights into the differences between Medicare’s policy and its Conditions of Participation during a recent webinar.

Explaining the DifferenceMedicare Policies

Maxim pointed out that the differences between policy and the conditional requirements comes down to what can be billed and what are the quality standards for the services provided.

“The Conditions of Participation are dealing primarily with quality, whereas Medicare policy is related to payment,” said Maxim. And while there is a difference, that doesn’t mean both aren’t important and must always be followed.

“If Medicare policies are not followed, you are audited and if you do not have documentation to support those policies, you’re not going to get paid,” said Maxim “Oftentimes, with PDGM, staff members are not getting past that first 30 days. They’re not understanding what they need to do to keep that patient who continues to qualify for services on for longer.”

Maxim says that the problem is often that clinicians do not understand Medicare policy. “Every piece of documentation we submit to the Medicare program for review [needs to be] as pristine as we can possibly get it,” she said.

Assessment and Documentation

Proper assessment and documentation is something Maxim feels is critical in ensuring quality care, meeting Medicare requirements, and receiving payment for services.

“Complete and detailed documentation is going to be the key for agency payment by the Medicare program,” Maxim said.

Maxim pointed out certain services covered under Medicare policy may include observation and assessment, management and evaluation of a care plan, maintenance therapy, teaching and training activities, administration of medications, wound care, ostomy care, rehab nursing, venipuncture, skilled nursing visits, and more.

She also cautioned that agencies need to be prudent with the funds they receive from Medicare, viewing them as a potential “short-term, interest-free loan” until undergoing any audit. Until their documentation is reviewed and approved, there are no guarantees.

“Medicare is an insurance and it’s not free,” said Maxim. “Medicare policy provides us with a list of covered items. If experiencing an audit, and if the documentation is not there to cover the covered service, you’re not in compliance with that Medicare policy and you will not be paid for the services.”

Communicating With Physicians

Maxim further emphasized the importance of frequent contact with physicians, adherence to care plans, and ensuring that care plans are simple with individualized plans and goals that are achievable.

“You want to make sure that you have orders that physicians are actually going to read and to determine that they make sense and they’re going to sign off on them,” said Maxim.

“Keep your plan of care simple.”

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Axxess Home Health, a cloud-based home health software, streamlines operations for every department while improving patient outcomes.

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