On April 10, 2014, the Department of Health and Human Services Office of Inspector General (OIG) released its most recent investigative report related to home health agencies. The report, entitled, “Limited Compliance With Medicare’s Home Health Face-To-Face Documentation Requirements,” found that 32% of home health claims submitted under the Medicare program and that required face-to-face encounters, representing approximately $2 billion in home health services, did not include the correct documentation. OIG’s findings and recommendations are discussed below. In concurring with OIG’s recommendations, the Center for Medicare and Medicaid Services (CMS) described its general plan to eventually conduct a record review of all home health agencies that bill Medicare, including engaging its Supplemental Medical Review Contractor to validate that the face-to-face encounter is documented.  As in all such reviews, any identified overpayments due to missing or inaccurate documentation (among other things) may result in claim adjustments or recoupment actions against home health agencies.

The Face-To-Face Encounter Documentation Requirement

Under the Patient Protection and Affordable Care Act (ACA), home health agencies are required to comply with enhanced fraud-prevention measures. This includes, among other things, a requirement that physicians (or certain practitioners working with them) who certify beneficiaries as eligible for Medicare home health services document face-to-face encounters with the beneficiaries. To qualify for home health services reimbursable under the Medicare program, the patient must (1) be homebound except when receiving outpatient services; (2) require intermittent skilled nursing care, physical therapy, or speech therapy, or continuing occupational therapy (if applicable); (3) be under the care of a physician; and (4) be under a plan of care that has been established and is periodically reviewed by a physician. 42 C.F.R. § 424.22. The initial need for homebound status must be established by a physician and recertified every 60 days in order for the home health agency to be eligible for certain payments related to the patient’s care. Note that the regulation also includes limits on certifications and other actions by physicians in specific circumstances, such as when no exception applies and there are financial relationships between the physician and the home health agency.  As a result, it is important to confirm that the certifying physician is eligible to perform that certification. In addition, if the patient does not receive at least one covered visit of specific services during the 60-day period, the plan of care will be considered terminated.

As part of complying with these requirements, the physician must document a face-to-face encounter with the patient for establishing the initial plan of care. The documentation must be completed by the physician, signed by the physician, and indicate that the face-to-face encounter related to the primary reason that the patient requires home health services. The physician who completes the form can be the certifying physician, the physician who cared for the patient in an acute-care or post-acute-care facility, or a permitted nonphysician practitioner who completed the face-to-face encounter. In addition, there are other documentation requirements that the information submitted must meet, such as including a narrative.

Common Errors Identified

Home health agencies can improve their practices by avoiding the most common errors in documentation. The most common errors found included:

  • Failure to have the signature of the certifying physician.
  • The date of the encounter was not within a required timeframe.
  • The documentation lacked an appropriate title.
  • The date of the encounter was not provided.
  • The date when the physician signed the document was not provided.

In addition, OIG determined that the narrative portion of many of the documents provided were not sufficient to support the claims submitted. For example, narratives did not meet guidance issued by the CMS or even specifically included phrases and language that CMS identified as inappropriate for the narratives.

Because home health agencies rely on physicians to complete the forms accurately and timely, and those agencies are held accountable if physicians fail to do so, some initiatives discussed in the report to improve compliance include strategies like creating forms and implementing specific check boxes to ensure the required information is included. 

OIG Recommendations

OIG recommended, and CMS concurred, that CMS (1) consider requiring a standardized form to ensure that physicians include all elements required for the face-to-face documentation, (2) develop a specific strategy to communicate directly with physicians about the face-to­-face requirement, and (3) develop other oversight mechanisms for the face-to-face requirement. It is not clear exactly how or when changes will be implemented, but in the meantime, home health agencies can review the applicable requirements and ensure that their documents are complete and compliant.