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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

“2 Midnights” Rule: What it Means for Home Health Agencies?

October 4, 2013 03:31 PM

The Centers for Medicare & Medicaid Services released its controversial “2 midnights” rule in the 2014 Medicare Inpatient Prospective Payment System (IPPS) final rule.

Under the “2 midnights” rule CMS has set both a benchmark and a presumption for when an inpatient satay would be considered appropriate.  If the inpatient stays spans two midnights, CMS will presume that the stay is reasonable and necessary. In addition, admitting clinicians can use the “2 midnight stay” as a benchmark in determining when it is appropriate to admit a patient as an inpatient rather than keeping the patient in an outpatient status in an observation unit.

With this provision, CMS intends to decrease the number of extended observation stays, while decreasing the number of short inpatient stays (less than 2 midnights) billed under Part A that should be billed under Part B as outpatient services. Extended observation stays have a negative impact on beneficiaries since they require a 20 % co-pay for the service and do not count towards the 3 inpatient day stay required for Medicare coverage skilled nursing facility (SNF) admissions. Payments to hospitals for inpatient services provided under Part A that should have been provided as outpatient services billed to Part B are considered Medicare overpayments to the hospital.

CMS will permit physicians to apply the time a patient spends receiving outpatient services, such as an observation unit, to count towards the “2 midnights” stay when considering whether to continue services as an inpatient. 

“…we expect that the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service. In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary’s total expected length of stay. For example, if the beneficiary has already passed 1 midnight as an outpatient observation patient or in routine recovery following outpatient surgery, the physician should consider the 2 midnight benchmark met if he or she expects the beneficiary to require an additional midnight in the hospital.”

 However, the count for a formal inpatient stay begins with the physician’s order for an inpatient admission, and does not include time the patient spent receiving outpatient services. Therefore, only the time the patient actually spends as an inpatient will count towards the 3 day inpatient stay requirement for a SNF admission. 

“We reiterate that the physician order, the remaining elements of the physician certification, and formal inpatient admission remain the mandated means of inpatient admission. While outpatient time may be accounted for in application of the 2-midnight benchmark, it may not be retroactively included as inpatient care for skilled nursing care eligibility or other benefit purposes. Inpatient status begins with the admission based on a physician order.”

CMS will instruct medical reviewers to not focus on inpatient admissions that span greater than two midnights, since these stays will be presumed to be appropriate.  Inpatient stays that span are just two midnights will likely be reviewed to ensure appropriateness of care and that hospitals are not gaming the system. Medical review will be more intensive on claims with inpatient stays that span 1 or less midnights to evaluate whether the services are appropriate to be billed as inpatient services under Part A.

If an inpatient stay that has been billed as Part A is determined that it should have been under Part B, claims adjustment will be made and the hospital will receive a lower reimbursement rate for the care, in addition to having to collect any co-payments due from the Medicare beneficiary.

So what does all this mean for home health agencies? Well, a lot will depend on how hospitals respond to the “2 midnights” provision and the strategies they develop. A hospital that has a high number of short inpatient stays might adjust their admission policy to increase their observation stays.  Conversely, a hospital that has a high number of lengthy observation stays will want to review their admission policies to increase the number of patients that are treated as inpatients.   

If hospitals have shorter observation stays there will likely be less outpatient physical therapy (PT), occupational therapy (OT), and Speech Language Pathology (SLP) services provided by hospitals that fall under home health consolidated billing rules. In other words,  therapy that was provide as an outpatient would now be provided as an inpatient, the hospital claims will process and agencies will not be pressured  to reimburse the hospital for denied therapy services. 

On the other hand, if a hospital increases observation unit admissions, agencies could see more bundled therapy being provided. However, even though the observation stays might be more frequent, the length of the stays will be short in duration. Further, agencies are not required to reimburse the facility for bundled therapy if there is no arrangement with the facility to provide the service.

For hospital inpatient claims that are denied under Part A and billed to Part B, CMS, in the final rule, agreed that PT, OT, and SLP services could be billed as an Inpatient–Part B claim. The National Association for Home Care & Hospice is waiting to hear from CMS regarding whether therapy billed on an Inpatient–Part B claim will paid if the patient is under a  home health POC or will the hospital claim be edited against the  home health agency’s claim and be denied?   

Another outstanding question is how agencies are to treat hospital transfers for the purpose of completing the OASIS. Regardless of how hospitals react to the “2 midnights rule”, it is expected that there will be an increase in the number of patients that are initially admitted to outpatient observation that will be admitted as inpatients during the hospital stay. Agencies are required to complete the Transfer and Resumption of Care (ROC) OASIS whenever a patient is a hospitalized for 24 hours or more, for reasons other than diagnostic testing. 

Agencies will most likely be required to complete the transfer/ROC OASIS if the patient’s status is changed from observation to inpatient.  In addition, a transfer/ROC OASIS is only required if the inpatient status is greater 24 hours. Tracking the status of these patients could prove to be a challenge for agencies. Currently, the majority of patients admitted to observation units remain in observation until they are discharged from the facility.

Click here  to view the final IPPS rule and to learn more about the “2 midnights” provision.  




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