It’s a home health crackdown, but your phone’s going to ring

August 5th, 2014 - Scott Kraft
Categories:   Audits/Auditing   Office of Inspector General (OIG)   Physicians  

Don’t be surprised if you suddenly start to get persistent calls from home health agencies concerning patients you’ve referred for home health care.

Medicare has directed its supplemental medical review contractors (SMRCs) to crack down on the face-to-face visit rules required to certify home health care by auditing five records from every home health agency in the country to ensure they have the proper documentation of the face-to-face visit.

Because the face-to-face visit has to be done by the physician practice, expect the agencies to be calling to make sure they have the right documentation.

The face-to-face visit requirement to certify and recertify patients for home health care came about under the Affordable Care Act (ACA) as a means to reduce what CMS considered to be the overutilization of home health services believed to potentially be not medically necessary.

At the point of implementation, the provision that each patient referred for home health service have a face-to-face encounter for medical necessity challenged home health agencies and physician providers alike.

The agencies were concerned that their revenue was in jeopardy due to the added documentation requirement. Physician advocates were angry that they were being asked to complete yet another paperwork burden for no additional pay.

While a lot of those hiccups seemed to have gone away, an HHS Office of Inspector General (OIG) audit released in April showed that, of the 644 face-to-face encounter documents reviewed by OIG auditors, 32 percent did not meet Medicare requirements, which extrapolated to $2 billion in annual overpayments.

The face-to-face documentation essentially requires the physician to certify that a face-to-face visit related to the patient’s need for home health services took place, that the patient is homebound and that the patient needs medically necessary skilled home care. This must be communicated by the physician in a narrative specific to that patient’s need.

The physician may use a template for this, providing it is neither furnished nor completed by the home health agency. This visit must occur within 90 days prior to the start of home health care or within 30 days of it beginning.

Of the home health cases found to be lacking, 10 percentage points lacked face-to-face documentation and approximately 25 percent were missing one of the above required elements. The narrative statements by the physicians were found to be inconsistent.

Expect home health agencies to push on patient specificity, because that is the key to supporting their encounters. For example, a statement that it is taxing to leave home was found by OIG to lack specific patient detail about the need for home health. Instead, it just lifts a line from the CMS definition of homebound.

Examples cited that do not support home health skilled service include too weak to drive, family needs help, unable to furnish own wound care and diabetes. Examples that don’t support homebound status include unable to leave home, dementia, functional decline, weak and unable to drive.

OIG also challenged many of the uses of check boxes on certification forms, saying that CMS intended these only for limited situations when generated by the physician or the physician’s electronic health record system.

Four recommendations were made by OIG to CMS to reduce errors. First was that CMS use a standardized form for the face-to-face documentation. CMS agreed to consider it, though noted it would eliminate some provider flexibility to port information from the current medical record. Second was to require physicians to include their NPI, which CMS said would not add value.

The third, to provide more education, was agreed to by CMS. The fourth, more oversight, is why you might be getting more calls from home health agencies very soon.

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