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n March of this year, the Office of Inspector General (OIG) issued an Advisory Opinion (No. 06-01) against home healthcare agencies providing free home safety assessments. The opinion was based on a review of the practice of physical therapists providing free preoperative home safety evaluations for prospective patients who are scheduled for orthopedic surgery. The OIG advises home healthcare agencies to refrain from free assessments in person as well as those done telephonically because they have more than nominal value and therefore constitute remuneration. The bottom line is that they are likely to influence the patient’s selection of a particular home healthcare agency.
       If you work for a home healthcare agency, you may be wondering how this impacts your business and whether it applies to other activities besides preoperative assessments. The following questions and answers were developed in response to this opinion to help those of us in home healthcare understand how this opinion directly affects day-to-day operations.

Questions and Answers

        Question: Does this change the process of referring a patient to home healthcare?
        Answer: No, referrals can continue to be processed in the same way they have always been handled. A home healthcare agency that provides specialty programs can work with the physician to educate him or her to the quality of its program, and if the physician is comfortable with the program he or she can certainly discuss this with their patients. You just cannot perform home assessments until the patient is admitted.
        Question: Will this decision impact my patient’s clinical outcomes?
        Answer: No. The absence of an in-home safety evaluation or the preoperative telephonic assessment should not impact your patient’s clinical outcome. Once the patient has had surgery and an agency receives the referral for home healthcare, the safety of the patient and his or her home environment will be assessed at the start of care. The real value of your services is the delivery of care based on an approach that includes evidence-based clinical pathways or protocols that result in better outcomes for the patient.
        Question: Does the OIG advisory opinion apply to all home healthcare agencies?
        Answer: Yes, the opinion applies to all home healthcare agencies that conduct home safety evaluations of any type. (Technically, the opinion applies only to the requesting entity, but the opinion is considered a precedent and can be applied to all home healthcare agencies by regulators.)
        Question: Why is the preoperative safety evaluation and telephonic assessment considered an inducement by the OIG?
        Answer: Because the safety assessments have more than nominal value. An inducement is defined as the provision of something of value without the expectation of payment, in order to induce behavior (eg, referrals). The OIG advisory opinion deems preoperative safety evaluations and telephonic assessments to be fits for this definition, considering them inducements because they have value to the patient.
        Question: Can a copy of the advisory opinion be shared with a referral source?
        Answer: Yes, by all means. That is part of why the OIG issued a formal opinion—to document something that clearly states that home healthcare agencies should not be doing these free safety evaluations before the patient is admitted to his or her home healthcare agency. The opinion is posted on the OIG website and can be viewed by visiting www.oig.hhs.gov/fraud/advisoryopinions/opinions.html. It is important for referral sources to understand that if they continue to use a provider that offers free home safety evaluations, they may be at risk for accepting what the government has determined to be “inappropriate inducements.”
        Question: In lieu of the in-home safety evaluation or telephonic assessment, is there anything one can do to ensure that the patient is discharged to a safe environment for postoperative recovery?
        Answer: Well, yes, but the responsibility for ensuring this rests with the hospital or skilled nursing facility and the physician. As part of the discharge planning process, the facility is responsible for determining the appropriateness for every patient discharge to the home setting. When a patient is admitted to a home healthcare agency, the nurse or therapist opening the case is also responsible for ensuring that the environment is safe and that the patient’s medical needs can be adequately met there. Otherwise, they should not admit the patient but should instead help make arrangements for placement in another care setting. The specifics of these requirements are usually stated clearly in the home healthcare agency’s admission policy.
        Question: Does this OIG advisory opinion apply to patients who area covered by non-government insurance (or agrees to pay privately)? Can they receive preoperative home safety assessments?
        Answer: No, the opinion does not apply to these patients; therefore, yes, they can receive preoperative home safety assessments as long as someone other than the home healthcare agency is willing to pay fair market value for the service. The restriction does, however, apply to patients who are covered by government payers, such as Medicare and Medicaid.
        Question: What about a Medicare Advantage patient whose benefits will cover a pre-operative assessment?
        Answer: Yes, if the payer agrees to pay for the service it may be provided. But the home healthcare agency will have to admit the patient at that time to be reimbursed for the services.
        Question: Can a Medicare patient be admitted for services preoperatively?
        Answer: Well, yes, though experts tell us that it is not likely that your typical preoperative orthopedic patient would meet the criteria. It really comes down to the issue of medical necessity and coverage. Like any other admission, the patient must be homebound, he or she must require skilled nursing or therapy services on an intermittent basis, and the services must be reasonable and necessary for treatment of an illness.