CMS to allow authorized hospitals to provide inpatient care in patients’ homes

CMS announced on November 25 that it is building on the flexibilities granted by the Hospitals Without Walls program to launch the Acute Hospital Care at Home program. Under this program, eligible hospitals will be allowed to treat certain inpatients in the patient’s home.

To participate in the program, hospitals must apply through an online portal. Participating hospitals are required to regularly report quality and safety data. Waivers granted under this program are individual waivers and are not blanket waivers. If a hospital has provided acute hospital services in patients’ homes to at least 25 patients, the process will be expedited. If a hospital has provided acute hospital services in patients’ homes to fewer than 25 patients, the hospital will complete a more detailed waiver request and will be required to report monitoring data more frequently.

Before providing acute hospital care in a patient’s home, the hospital is required to screen for medical and nonmedical factors such as working utilities, assessment of physical barriers, and domestic violence concerns. Patients can only be admitted from emergency departments and inpatient hospital beds. A physician must conduct an in-person evaluation before starting care at home. A registered nurse must evaluate each patient in the program once daily either in-person or remotely. In-person visits by a registered nurse or a mobile integrated health paramedic must be conducted twice daily.

Eligible patients must be given the option to receive traditional hospital care or participate in the program. No patient can be required to receive hospital care at home.

Revenue integrity professionals at participating hospitals will need to consider the charging and billing ramifications. NAHRI Advisory Board Member Kay Larsen, CHRI, CRCR, revenue integrity specialist at Adventist Health Glendale in Glendale, California, says that her hospital is participating in the program although they have not yet treated many patients through it. However, she’s already noted several issues that revenue integrity professionals need to be aware of, such as ensuring the performing location is correct.

“When charges are assigned the following day, the system may assign the current patient location instead of the original performing location,” Larsen says. “The performing location affects the cost center, which the vendor uses to determine billing.”

Determining how and what to charge for the room rate is also a concern, Larsen says. This can be a complex question and revenue integrity professionals may need to consult with their vendors, review their room rate policies, and examine CMS’ requirements.

“From a charge perspective, there is also the consideration that per the Provider Reimbursement Manual, CMS requires there be a relationship between cost and charge. For an inpatient room rate in the hospital, there are lots of services included that would not be included when the ‘room’ is in the patient’s home,” says NAHRI Advisory Board Member Denise Williams, COC, CHRI, senior vice president of revenue integrity services at Revant Solutions in Raleigh, North Carolina. “Overhead is less, no meals, no housekeeping, electricity, etc., that are a cost to the hospital.”

However, there are costs associated with providing care in the patient’s home, such as sending staff to the home. Revenue integrity professionals may consider setting a room rate for “inpatient at home” that captures the actual cost involved, Williams says. This would be consistent across all inpatients treated at home while accounting for the differences in cost compared to an inpatient in the hospital. Charging could occur at midnight as it would for any other inpatient.

Regardless of the method used, hospitals should be prepared to answer patients’ questions and provide a clearly documented and consistent defense of the charges that is based on CMS’ policies.

Hospitals will also need to ensure that inpatients treated at home truly require acute hospital care, says NAHRI Advisory Board Member Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president of physician advisory services at R1 RCM in Chicago.

“Most patients are admitted to the hospital because of the need for 24 hour a day monitoring by skilled personnel. For this program, CMS only requires that emergency personnel must be able to respond within 30 minutes,” Hirsch says. “That immediately raises the specter of whether these patients even require inpatient care in the first place if they are able to be sent home with only three visits a day, and there is no indication that these admissions will be exempt from audit.”

For more information, see CMS’ FAQ document and comments from health systems that are already participating in the program.