Community Education Policy

Community Education Policy

Record Keeping and Reimbursement Guidelines

Standard

Community Education provides a link between the hospital, SNF (skilled nursing facility) or other healthcare provider and the home health agency, contributing as an educational resource. The costs related to these activities are allowable by Medicare to the extent that they are necessary for patient care and do not duplicate services which are or should be performed by the hospital or SNF. However, Medicare clearly states “selling” or soliciting for home care services is a non-allowable and non-reimbursable cost, as well as any cost not directly or indirectly associated with patient care.

Criteria

The activities which are/are not reimbursable by Medicare are governed primarily by federal regulations and HCFA’s Provider Reimbursement Manual which serves as the interpretive guide to the regulations. The Manual provides examples of the types of activities which are and are not reimbursable. There are also cases challenging decisions of the Fiscal Intermediary (FI) denying reimbursement which provide further clarification.

Careful reading of HIM 15 § 2113.4 is critical for anyone responsible for record keeping related to Community Education. Keep in mind that just because an activity is not reimbursable by Medicare does not mean that the service cannot be provided--that is a business decision to be made by management based on a cost/benefit analysis and the needs of your community. You may provide the service; the agency just may not be reimbursed by Medicare for the service.

• The general rule governing reimbursement is that all costs must be related to patient care. The government’s position on reimbursement for expenses related to patient care is set forth in regulations, first as a general principle statement, and then in specific definitions and application provisions.

• All payments to providers of services must be based on the reasonable cost of services covered under Medicare and related to the care of beneficiaries. Reasonable cost includes all necessary and proper costs incurred in furnishing the services.

Necessary and proper costs are costs that are appropriate and helpful in developing and maintaining the operation of patient care facilities and activities. They are usually costs that are common and accepted occurrences in the field of the provider's activity.

Examples of activities which are allowable under Medicare regulations include:

• Activities which ease the patient’s transition from hospital, SNF, or other healthcare provider to the home after a referral has been made by a physician. Activities prior to a referral are not reimbursable as coordination. The reasoning is clear - you cannot coordinate the care of a patient that is not yet your patient.

• Explaining agency policy to patients and family after a referral.

• Creating a home care plan prior to discharge.

• Making sure the agency can meet the patient’s needs.

• Serving as an educational resource for the hospital or SNF on home health services including providing training for their staff to assist them in establishing home care policies.

• Educating physicians about the services available through the agency

NOTES

To meet the “related to patient care” test, the community education must be for the care or assistance of the provider’s patients.

The concern is that repeat or multiple visits to the same referral sources may appear to have less to do with providing education and information than marketing and patient solicitation. Therefore, frequent repeat visits to the same referral sources must be avoided, if the activity is to be reimbursable.

Documentation

Records maintained and submitted by the agency to claim allowable costs for community education functions must be auditable.

• The records must permit a determination of the exact type of activities taking place and the amount of time spent on each. Time should be recorded in 15 minute intervals.

• The time records must document with specificity the type of training course that was given, the person(s) who attended, the practices and policies that were developed, and/or the physicians who were educated.

• In addition to the time records, the home care agency must maintain documentation concerning the educational services provided by the home care agency, including:

• Attendance sheets signed by the hospital, SNF, or other healthcare provider participants in the training activities,

• Copies of hospital or SNF policies or other healthcare provider

practices developed,

• Signed attendance statements by physicians and their staff verifying that they were educated as to available home care services.

• The Community Education time record will assist in determining the exact nature of allowable costs under these rules.

• All personnel in positions of community education or any other related function must use this form on a daily basis and submit to the immediate supervisor/payroll department.

Adequate cost information must be maintained to support payments made for services to beneficiaries. Data must be adequate and capable of being audited. Patient services must include the patient name, date and service provided or discussion held with the patient and the time spent on the service. Records must be created contemporaneously with the service. Prospective record keeping is unacceptable.

Key factors which govern record keeping are verifiable, contemporaneous and auditable records. The bottom line is that your daily business records must clearly represent what, when, for whom and for how long a service was provided.

CAUTION: If an intermediary determines that a provider does not maintain or no longer maintains adequate records for the determination of reasonable cost under the Medicare program, payments will be suspended until the intermediary is assured that adequate records are maintained.

Advertising

The Provider Reimbursement Manual on reimbursement of advertising costs, provides that:

Advertising costs incurred in connection with the provider's public relations activities are allowable if the advertising is primarily concerned with the presentation of a good public image and directly or indirectly related to patient care.

Whether advertising costs will be paid depends on whether they are appropriate and helpful in developing, maintaining, and furnishing covered services to Medicare beneficiaries. The intermediary will consider the facts and circumstances of each situation... To be allowable, such costs must be common and accepted occurrences in the field of the provider's activity.

Reimbursable Advertising

• Providing information related to visiting hours.

• Advertising for recruiting medical, paramedical, and administrative personnel are allowable if the personnel would be involved in patient care activities or in the development of the facility.

• Sponsoring and seminars on health related topics for the provider or Medicare beneficiaries. Events for the community at large (health fairs) are not reimbursable since they are not related to the care of Medicare beneficiaries. Providing written material including magazines and newsletters on health related issues and available services, to Medicare beneficiaries and/or provider.

• Reasonable production and distribution costs of informational materials to professional groups and associations, such as those listed above, are allowable if the materials primarily refer to the provider's operations or contain data on the number and types of patients served.

The contacts communicate information on facilities available to persons who require it to provide patient care, and serve other purposes related to patient care, e.g., exchange of medical information on patients in the provider's facility, administrative and medical policy, utilization review, etc. The materials should contribute to an understanding of the role and function of the facility as a provider of health care in the community.

Very little by way of advertising is being allowed. For example, brochures which feature the HHA name but do not educate are being disallowed or limited to distribution to the physicians or facilities who admit patients and number of admitted patients. Yellow pages are limited to one to two lines without large type, bolding, borders, etc.

Key factors governing the allowability of advertising/public relations activities are (1) their primary purpose; (2) their helpfulness/appropriateness in developing and maintaining services; and (3) whether their primary focus is on presenting a good public image in a way that is common and accepted.

Non-Reimbursable Advertising

General advertising to promote an increase in the patient utilization of services is not properly related to the care of patients. Whether advertising is allowed as a cost to Medicare depends on whether it is directed primarily to Medicare beneficiaries and/or other providers.

Examples of activities/costs that are not allowable include:

• Fund-raising, including advertising, promotional activities, or publicity costs incurred for such a purpose, are not allowable.

• Advertising of a general nature designed to invite physicians to utilize a provider's facilities are not allowable.

• Advertising to the general public which seeks to increase patient utilization are not allowable. The FI may analyze the advertising copy and the recipient list to determine the real objective.

• Promotional activities to obtain new business.

• Any sales activities, training or even attending sales meetings.

• Costs associated with Health Fairs presented to the general public.

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Attachment to LL.015