Failure To Comply With Requirement For Documented Physician/Patient Face-To-Face Encounter Will Result In Denial/Overpayment Demand For Home Health Services

Correct documentation is always important.  Recently, HHS-OIG provided another example why.

HHS-OIG recently published a Report, “Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements.”  [Link]  HHS-OIG concluded, after an extensive audit, that 32% of home health claims that required face-to-face encounters were improperly documented and failed to meet Medicare requirements, resulting in $2 billion in Medicare payments that never should have been paid.

To qualify for home health services, Medicare beneficiaries must: 1) be homebound; 2) need intermittent skilled nursing care, physical or speech therapy, intermittent home health services, or other services; 3) be under the care of a physician, and 4) be under a plan of care that has been established, and periodically reviewed, by a physician.

In order for home health agencies to be paid, a physician must certify initially the beneficiary’s need for home health services and recertify that need every 60 days.  For the first certification, the physician must document (and sign) a face-to-face encounter with the patient.  The documentation must include:

  1. Certifying physician’s identifying information with physician’s signature;
  2. The face-to-face documentation must be title as such;
  3. The date of the face-to-face encounter must be documented;
  4. The face-to-face encounter must occur within 90 days prior to start of home care, or within 30 days after start of care; and
  5. The documentation must include a description of:
    • Why the patient is homebound; and
    • Why the skilled service is necessary.

Failure to document remains one of the most routine bases for overpayment demand by Medicare.  Given recent regulations promulgated pursuant to the Affordable Care Act, and recent MAC and court opinions overwhelmingly upholding overpayment decisions for lack of documentation, this report and audit is important guidance to home health care service providers.  We expect increased review of, and resulting overpayment demands to, home health care service providers as a result of this report.