The California Department of Industrial Relations/Division of Worker's Compensation asked RAND to help develop a fee schedule for home health services provided to injured workers. After consulting stakeholders, reviewing other payers' fee schedules, and interviewing WC administrators from other states, the researchers focused on options to create a single fee schedule covering the full range of services and made three sets of recommendations.
- What types of home care services are provided by the Workers' Compensation (WC) program?
- What features of existing fee schedules for home care services might serve as a model for WC?
- Are there model rules concerning unskilled home care services provided by relatives?
- What has been the experience of other programs in administering fee schedules for unskilled home care services?
- What coding system and billing forms should be adopted for use?
- What rules should be considered to clearly delineate the Medicare-based fee schedule from the IHSS-based fee schedule and from other WC fee schedules?
The California Department of Industrial Relations/Division of Worker's Compensation asked RAND to provide technical assistance in developing a fee schedule for home health services provided to injured workers. The fee schedule needs to address the full spectrum of home health services ranging from skilled nursing and therapy services to unskilled personal care or chore services that may be provided by family members. RAND researchers consulted with stakeholders in the California workers' compensation system to outline issues the fee schedule should address, reviewed home health fee schedules used by other payers, and conducted interviews with WC administrators from other jurisdictions to elicit their experiences. California stakeholders identified unskilled attendant services as most problematic in determining need and payment rates, particularly services furnished by family members.
RAND researchers concentrated on fee schedule options that would result in a single fee schedule covering the full range of home health care services furnished to injured workers and made three sets of recommendations. The first set pertains to obtaining additional information that would highlight the policy issues likely to occur with the implementation of the fee schedule and alternatives for assessing an injured worker's home health care needs. Another approach conforms most closely with the Labor Code requirements. It would integrate the fee schedules used by Medicare, In-Home Health Supportive Services, and the federal Office of Workers' Compensation. The third approach would base the home health fee schedule on rules used by the federal Office of Workers' Compensation.
Services provided to homebound injured workers vary widely.
- Home health care services provided to injured workers range from short-term care following an acute episode to longer-term nursing care and supportive services for seriously disabled workers who would otherwise be institutionalized.
Fee schedules for other public health care programs provide useful options for a WC home health services schedule.
- Allowances differ by the level of training/licensure and employer of the care provider.
- Time-based rates are lower for an eight-hour shift than for services performed over shorter time periods.
- Estimated costs of in-home services come with an aggregate monthly cap.
There are several viable ways to structure a home health services fee schedule.
- The largest question to be addressed is that of services performed by family members.
- IHSS has useful rules on family member services, and other programs furnish few models.
Fraud and abuse must be anticipated and avoided.
- Most state WC programs that cover supportive services limit coverage to personal care services and rely on preauthorization and time-limited authorizations.
Multiple billing forms will likely need to be adopted.
- Billing codes adopted from other programs would have both duplications and gaps.
- Separating Medicare-based rules from IHSS-based rules will be a complicated undertaking. Specificity and attention to detail will be vital.
- Convene an expert panel representing different perspectives to consider issues related to an assessment of an injured worker's need for home health services.
- Evaluate whether the IHSS guidelines can be applied to functional status scores for ADLs and IADLs generated with the OASIS instrument and assess whether the resulting estimates of service needs are comparable.
- Partner with payer(s) and/or WC case management organizations for a sample of WC patients for whom skilled care is prescribed to obtain a better understanding of the home health services currently being provided.
- Confirm the skill levels required to furnish paramedical services under the WC program.
- Require that any caregiver providing attendant services be either employed by a licensed home health agency or registered with the Department of Social Services unless the payer and worker agree to an unregistered aide.
- Require that the physician, the health care professional conducting the assessment, and the injured worker (or representative) participate in the decision regarding whether long-term care services can be provided in a home environment safely and the type of arrangements for services.
- Use the IHSS guidelines as a starting place to determine the hours needed for supportive services.
- Assume that the IHSS restriction on services provided by family members would be a way to address the requirement that family members do not receive payment for services customarily performed prior to the injury.
- Consider whether to impose a cap on aggregate expenditures.
- Standardize the physician prescription forms and billing forms to be used for home health services.
Table of Contents
Current State of Home Health Care for Injured Workers
Medicare Home Health Services
In-Home Supportive Services
Other Home Health Services Under California's Medicaid Program (Medi-Cal)
Department of Veterans Affairs
Review of Policies from Other WC Programs
Creating a Fee Schedule for California
Summary of Findings and Recommendations for Creating an OMFS for Home Health Care Services
Data Collection Methodologies
California Academy of Physician Assistants Survey on IHSS Wages as of May 28, 2012
Overview of Policies on Attendant Care Services
Overview of Policies on Services Provided by Family Members