NAHC says HCFA capitulates on patients’ homebound status
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON The National Association for Home Care (NAHC; Washington) declared victory last week when the Health Care Financing Administration (HCFA; Baltimore) issued a program memorandum instructing its intermediaries to grant favorable appeal decisions regarding the homebound status of beneficiaries unless there has been a change in the patient’s condition.
According to NAHC, this policy change is the first time that HCFA has ever formally allowed a prospective effect to a favorable appellate decision. "Generally, HCFA has not acquiesced in favorable appellate decisions, requiring both patients and providers to pursue repeated appeals on the same issue," the association said.
NAHC said the program memorandum represents an attempt by HCFA to settle the homebound lawsuit O’Neal v. Shalala, which the association brought in 1998 to challenge HCFA’s application of the definition of homebound. In that suit, several beneficiaries won favorable appellate decisions from administrative law judges only to have the intermediary reject subsequent claims for payment.
Under the new policy, intermediaries must take several steps to effectuate a favorable final appellate decision that a beneficiary is "confined to home" rendered on or after July 1, according to NAHC. In addition to paying the claim that was subject to the favorable financial appellate decision, the intermediary must promptly pay or review all claims that have been denied or that are properly pending in any stage of the appeals process; all claims that have been denied where the time appeal has not lapsed; and all future claims submitted for this beneficiary. Any claim that could be reopened subject to the 12-month reopening provision must be reopened during a one-year grace period starting on July 1 and ending June 30, 2001, the association added.
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