Trouble at the border: Yo quiero mi licencia
Be sure your staff's interstate licenses are current
In the past, with the exception of home health care agency chains, most providers were single agencies covering a small, select area. Today, all that is changing. In order to react to the new business climate, those agencies still in business are having to find increasingly resourceful ways of staying afloat. One means of keeping ahead of the game is through a solid - and expansive - client base that increases admissions.
The search for business has caused some agencies to cross state lines to find referrals. Granted, if an agency and its professional staff are licensed to conduct business in a neighboring state there shouldn't be any problems. It gets tricky, however, when an agency, or its staff, isn't properly licensed.
Although it's hard to believe that any agency would agree to take on a case in a state in which it wasn't licensed, says Cathy Frasca, RN, BSN, FACHCA, vice president of Home Health Services South Hills Health System in Homestead, PA, it happens. "Insurance companies are asking agencies how wide an area they cover. They want wide coverage but don't want 100 different home health care agencies covering one area," says Frasca. "Further, when payers contract with preferred providers, they expect a full spectrum of services. So when you're talking about a small agency, how can they afford to provide a full spectrum and all the subspecialty services that are required without branching out?"
No surprise then that many smaller home health providers have begun to cast their nets wider. Whereas some agencies opt to enter partnerships with other agencies, some instead have chosen to concentrate on their client base and accordingly, depend heavily on referrals from certain health care providers. The problem here is that sometimes an agency's clientele can be too expansive in that the area they cover exceeds the agency's primary service area - and, depending on an agency's licenses, that's where the trouble starts.
Border patrol
"People are just so overwhelmed with worrying about costs, who will be reimbursing them, and where they'll be getting referrals. When someone is dealing with all these pressures and stresses, they may not even be thinking there's a boundary problem," she explains.
Adding to the confusion is the fact that licensing rules vary from state to state and sometimes even the rules are muddied. Take the example of home health care agencies located near the Illinois-Missouri border. "At one point," says Kathryn Christiansen, DNSc, RN, executive director of the Chicago-based Rush Home Care Network, "agencies were told that if they practiced across the state line they would need to have a licensed physician in both states.
"We were told that patients would have three months in which to get a physician in their own state to refer them to the agency, and during that time, there was some leeway whereby the agency could continue to service the patient. However, I can imagine that if you weren't careful, you might cross over that three-month time limit, and although a state agency might have given you the go-ahead, a national auditor could have come in and enforce the order to the letter of the law."
While Christiansen's agency, which is close to Indiana, doesn't provide service in that state, some agencies might well find themselves in a position similar to the one she described. Such vagaries certainly pose problems for agencies that are less than vigilant about keeping within the confines of their state. "There are probably some agencies that think if they're OK in one state, they're OK in another," says Frasca.
Unfortunately, they'd be wrong.
May I see your license, please
"Agencies need to make sure they're licensed in the states they're providing services and that all has to happen before the patient ever hits their door. If an agency doesn't have someone appropriately licensed to operate in a particular state, they shouldn't admit the patient," says Debra Payne, RN, associate director for the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) department of standards.
Should an agency be caught, the commission could hand down a Type One recommendation where the agency would then risk losing its accreditation. "Medicare certification and JCAHO accreditation are required to provide service within a state," explains Frasca. "You must satisfy all the rules and laws governing your state as well as all the federal laws, and if you violate that, you could lose it all. This is all very serious, and there are those that don't even realize this. They're making commitments to cover such and such and in doing so they're crossing state lines."
Sometimes such border crossings are merely the result of an agency trying to satisfy the request of a preferred referrer. But neither good intentions nor claiming ignorance of the law will help when the auditor comes knocking.
Since, as Payne points out, states don't give reciprocity when issuing licenses, the only way to stay out of trouble is by preventing it. An agency, says Frasca, needs to make a conscious decision as to whether it is going to offer service in another state and then inform the physicians and key referrers of this policy. Should an agency decide to practice in multiple states, licenses are in order. Some states have waivers allowing agencies to provide care in a rural area without the official state license, but Frasca cautions, since no state is so liberal as to allow an agency to apply for a waiver retroactively, that better be taken care of beforehand.
"It really falls to the leadership in planning and making sure they have the qualified staff and making sure that those who need to be are licensed in the states in which they're providing service," says Payne. Certainly it's up to the individual agency to get its licensed ducks in a row, but more than that, it's up to each home health care practitioner, says Payne. "As a professional, you don't forget where you are or aren't licensed. You know where you can practice, and if your organization sends you someplace where you can't, it's your license that's on the line."
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