Executive Summary

The Office of Inspector General ("OIG") released an April 2014 report sharing the results of its investigation of home health agencies' ("HHAs'") face-to-face documentation.  The report details both the manner and method of OIG's investigation and a number of its findings.  OIG noted that 32% of the home health claims did not have the requisite or complete face-to-face encounter documentation.  This failure resulted in $2 billion in payments that should not have been made.  The Centers for Medicare & Medicaid Services ("CMS") also noted there was limited compliance with the face-to-face documentation requirements and that CMS's oversight of the requirement is minimal. 

As a result of this study, OIG has recommended that CMS consider developing a standardized form for physicians to use that would help ensure that all required elements of the face-to-face documentation are gathered.  Further, OIG recommended CMS 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. CMS agreed with all of these recommendations.

Background 

The Patient Protection and Affordable Care Act ("ACA") requires physicians who certify beneficiaries as eligible for home health services to document the face-to-face encounters. This encounter and requisite documentation is a condition of payment.  The study was designed to review compliance with those requirements.

OIG indicated three purposes for the study:

  1. To determine the extent to which physicians who certified home health services documented their face-to-face encounters with beneficiaries within the required time frame;
  2. To describe the nature of face-to-face documentation; and
  3. To assess CMS's oversight of the face-to-face requirement.

Ultimately, OIG reviewed 644 face-to-face encounter documents in performing the study. The documents were reviewed to confirm the encounters and ensure that each contained the required documentation.  OIG also interviewed the four Home Health and Hospice Medicare Administrative Contractors to ask how they ensure the HHAs are meeting the face-to-face encounter requirements.  OIG also looked at CMS policies and procedures.

Discussion

CMS's Process for Analyzing the Data. CMS identified a correlation between home health claims data and physician claims data.  The agency started by identifying all Home Health Medicare Part A claims from January 1, 2011 through March 31, 2012, amounting to 7,835,502 claims.  Out of these 7.8 million claims, CMS determined those claims in which a face-to-face encounter would have been required, which is characterized as an "initial episode."  The agency determined 54% of the documentation it reviewed would require a face-to-face encounter starting from January 1, 2011.  However, because the face-to-face requirement did not go into effect until April 1, 2011, CMS eliminated all the claims for services prior to April 1, 2011.  This elimination reduced the total number of claims in their universe to 2.4 million.  Having identified the 2.4 million claims that would have face-to-face documentation, CMS reviewed Medicare Part B data and began looking for those claims that had a date of service from 90 days prior to or 30 days after the start of home health care.  CMS can cross reference data amongst providers, allowing the agency to determine a number of errors that it has not been able to in the past.  Through this process of cross referencing, the agency found that 68% of the claims had a matching physician claim for evaluation management.  This displays that in 68% of the cases, a physician had made a claim for a doctor's office visit in the time frame for face-to-face.

The report showed that 32% of the claims did not have a prior billed claim for a physician visit.  CMS recognized that with patients coming in to the hospital and other facilities, they may not have been building a claim.  However, it did not appear that the result was very surprising to OIG.  OIG stated specifically in the report that the agency found no relationship between the presence or absence of a claim by a physician for an office visit prior to a home health admission and the presence of face-to-face documentation in the agency's file.  In other words, when patients are going to home health from a facility, the providers are obtaining face-to-face documentation using the facility encounter.

Issues with the Error Rate. OIG selected a random sample of 644 home health claims to request face-to-face documentation.  The agency had a 95% total response rate for the 680 home health claims, indicating 95% of the agencies produced documentation. After OIG reviewed the documentation, the agency identified that 32% of the claims that required face-to-face encounters did not meet the Medicare face-to-face documentation requirements. This resulted in $2 billion in payments that should not have been made.  It is important to note that the auditors that are currently reviewing home health claims and face-to-face data are recouping claims for bad face-to-face data at a rate of 80-90%. These results indicate concern about the auditors' process since OIG found a significantly lower, by almost one-third, error rate to what the auditors are finding. It should raise concerns to CMS and others that the auditors are acting inappropriately.

Claims Missing Face-to-Face Documentation Requirements. The report includes that approximately 10% of the claims were missing face-to-face documentation.  This is notable because OIG received face-to-face documentation for 95% of the claims of the 680-claim sample.  Therefore, some of the documentation received must not have been face-to-face.  The number of claims without documentation is significant because 10% of the claims in the pilot project did not have documentation either.  OIG did not break down the 32% error rate.  The documentation missing includes: (a) 32% that did not have face-to-face documentation; (b) 17% failed for lack of certifying physicians' signatures; (c) 4% failed because the date of the encounter was not within the required time frame; (d) 3% failed for the lack of the appropriate title; (e) 2% failed for not including the date of the encounter at all; and (f) 2% failed for not having a date when the physician signed. 

The fact that more than half of the faulty documentation was incorrect due to lack of certifying physician signatures is problematic and indicates that HHAs need to be prepared to follow up with physicians to ensure physician signatures are included.  The report also documents the failure of the physician narrative to properly explain the patient's condition and need for services.  One of the ongoing issues agencies have had with narratives is that physicians are generally too short in their descriptions and fail to link the condition to the need of services. OIG noted that 12% of the documentation was missing the support of the patient's homebound status and 6% were missing narratives regarding need for skilled services. Also, some of the language did not appear to conform to the guidance about what an appropriate narrative ought to be.  OIG notes that in 16% of cases the documentation should refer to the patient's beneficiaries as weak, and 14% of the cases said the beneficiaries were unable to leave the home unassisted.  There was also not the requisite level of detail in the documentation. 

Inconsistency in Form Use. The report includes that the majority of physicians are not consistent on how they address forms with check boxes.  OIG questioned the use of check boxes as raising issues about the extent to which the narrative meets the Medicare requirements.  OIG notes that in some HHAs, face-to-face documentation contained more information than was necessary.  The report indicated that although this was not necessary, it was helpful and provided information that could be useful.  Examples of extra information provided include: National Provider Identifiers, the printed name of the physician and the name of a non-physician practitioner providing the care, and 58% of the documents were on either HHA letterhead or hospital letterhead. OIG indicated that most face-to-face documents have check boxes indicating the list of home health services, which is also a helpful addition.

OIG's Assessment of CMS Oversight. OIG also assessed CMS's oversight of the face-to-face requirement. The oversight was determined to be minimal because CMS lacks a specific program to oversee compliance; it only reviews the documentation when it conducts a medical record, and because the agency is only required on the initial episode, only a fraction of those reviews include face-to-face documentation.

OIG Recommendations. OIG concluded the report with recommendations.  OIG's prior recommendation was that CMS create a standardized form to ensure physicians include all required elements.  The industry has been requesting this type of form for a long time, and many providers have created their own standardized forms.  The standardized form will not only help with physicians getting it done correctly, but it will also decrease the confusion of having hundreds of different types of forms.

OIG also recommends that CMS provide additional training outreach to physicians about the face-to-face requirements, as opposed to simply relying on medical record reviews and audits.

Conclusion

Overall, the April 2014 report is notable because the OIG-determined error rate is so much lower than the auditors' identified error rate on face-to-face, which gives support to the industry's conclusion that CMS's auditors are incorrect on how they enforce the face-to-face requirement.  Also, it demonstrates that OIG is now aware of the burden this requirement has put on HHAs.  Specifically, the industry is in the unfortunate position of having a requirement that providers have to meet without the tools to enforce and without the responsibility over the actual documentation. The suggestion of a standardized form, stronger outreach and an oversight mechanism other than auditing may help elevate the burden. However, the burden will not be eliminated, and it is likely that a disconnect will continue.

Practical Takeaways

The results of the review are interesting for both the future in face-to-face requirements and the home health industry in general.

HHAs should take a look at their current face-to-face documentation policies and procedures.  Periodic self-audits or pre-bill audits may be helpful to ensure compliance with these requirements.