Every Medicare Home Health Agency in the Nation will be Audited by CMS

A 2014 audit by the Office of Inspector General (OIG) determined that only 32% of home health providers were in compliance with the face-to-face encounter documentation requirements under Medicare to be eligible for payment. As a result, OIG has recommended that the Centers for Medicare and Medicare Services (CMS) implement a number of improvements to the documentation process, which include the following:

  • Consider requiring a standardized form to ensure that physicians include all elements required for the face-to-face documentation;
  • Develop a specific strategy to communicate directly with physicians about the face-to-face requirement; and
  • Develop other oversight mechanisms for the face-to-face requirement

Moreover, CMS intends to conduct approximately five document-only reviews for every home health agency in the country to validate that the most recent face-to-face encounter is properly documented. CMS' Supplemental Medical Review Contractor (SMRC), StrategicHealthSolutions, LLC, will perform the review and CMS will provide further recommendations after receiving the results.

As background, payments by Medicare to providers who order home health services and to the agencies that provide the home health services are based on specific criteria and documentation requirements. In particular, a physician who establishes a plan of care for a patient that includes home health services must sign and date a certification establishing that the patient is eligible for those services. If the certification is not complete, the claim to Medicare from the physician for that certification (or recertification) of eligibility is not payable, and neither is the home health agency's claim for its services. As a result, it is essential for both providers to ensure that the certification and supporting documentation are properly completed and maintained.

To be eligible for Medicare home health services, a patient must meet certain requirements. The patient must (1) be confined to the home; (2) need skilled services; (3) be under the care of a physician; (4) receive services under a plan of care established and reviewed by a physician; and (5) have had a face-to-face encounter with a physician or allowed non-physician practitioner.

For a claim to be payable by Medicare, the physician must certify that:

  • The patient needs intermittent skilled nursing care, physical therapy, and/or speech-language pathology services;
  • The patient is confined to the home;
  • A plan of care has been established and will be periodically reviewed by a physician;
  • Services will be furnished while the individual was or is under the care of a physician; and
  • A face-to-face encounter:
    • occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care,
    • was related to the primary reason the patient requires home health services, and
    • was performed by a physician or allowed non-physician practitioner

Even though payment from Medicare to both physicians and home health agencies depends in part on this certification, home health agencies have little control over the certification process; and in particular, the proper documentation of the face-to-face encounter between the patient and the physician. Home health agencies are held financially accountable for failure to obtain the face-to-face documentation but have no authority to compel physicians to complete it either timely or accurately.

In response to OIG's recommendation for a standardized form to assist in documenting the face-to-face encounters, CMS also released proposed, voluntary electronic and paper versions of a clinical documentation template. CMS believes the use of clinical templates may reduce the burden on the physicians and practitioners who order home health services. CMS will be hosting a series of Special Open Door Forum calls to provide an opportunity for physicians/practitioners, home health agencies and/or all other interested parties to provide feedback on both a paper clinical template and the electronic clinical template for home health services.

PLDO will be assisting our clients in preparing for these SMRC reviews, as well as developing or updating compliance plans geared at meeting these and other compliance requirements. If you have questions about the upcoming reviews, the requirements or other health care compliance and billing concerns, please call Attorney Jillian Jagling at 401.824.5100 or email [email protected] We welcome your comments, questions and suggestions.

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