OIG Report Calls for Greater Oversight of Home Health Face-to-Face Requirement

A recent report from the Office of Inspector General (OIG) for Health and Human Services (HHS), is calling upon CMS to increase scrutiny of home health claims – specifically the required face-to-face documentation.  According to a report released April 9, 2014 on the OIG’s website, 32 percent of 644 randomly selected home health claims reviewed did not have documentation meeting the Medicare requirements for a face-to-face visit.  The OIG alleged that the insufficient documentation amounted to 2 billion dollars worth of overpayments.  The OIG stated that the Centers for Medicare & Medicaid Services” (CMS’) oversight of the home health face-to-face requirement is currently “minimal.”

The OIG recommended that CMS require a standardized form to ensure that physicians include all elements required for the face-to-face documentation.  The OIG also recommended that CMS develop a strategy to communicate directly with physicians about the face-to-face requirement.  Finally, the OIG recommended that CMS develop other oversight mechanisms for compliance with the face-to-face requirement.  According to the report, CMS concurred with this recommendation.

The OIG report also provides helpful guidance and recommended “best practices” that home health providers could use to better understand what the OIG and CMS contractors will be looking for when determining sufficiency of face-to-face documentation.

Face-to-face documentation must be completed by the physician.  A standard form can be provided to the physician, but it cannot be completed by the home health agency.  The home health face-to-face documentation must also include all of the following elements in order to meet the Medicare condition of payment:

–        The certifying physician must complete and sign the face-to-face documentation.  A physician who cared for the patient in an acute-care or post-acute-care facility, or a permitted nonphysician provider may conduct the face-to-face encounter so long as that physician or other permitted provider informs the certifying physician of the encounter.

–        The certifying physician must title the face-to face documentation in a manner that indicates that it is the face-to-face encounter documentation.

–        The certifying physician must also date and sign the face-to-face documentation.

–        The face-to-face encounter must occur within 90 days prior to the start of care or within 30 days after the start of care.

–        The face-to-face documentation must include a brief narrative that describes the reasons why the patient is homebound and why skilled services are necessary for treatment of the patient’s illness or injury.

The OIG report also contains CMS contractors’ examples of text that is considered insufficient to support home health claims.  Phrases that are considered insufficient to support homebound status include:

–        “weak”

–        “unable to drive”

–        “unable to leave home”

–        “dementia or confusion”

–        “functional decline”

Text that is considered insufficient to support the need for skilled services included:

–        “family is asking for help”

–        “continues to have problems”

–        “list of tasks for nurse to do”

–        “patient unable to do wound care”

–        “diabetes”

The OIG also stated that the phrase “taxing effort to leave home” was frequently used by physicians to explain a patient’s homebound status.  The OIG went on to note that, although this phrase is included in CMS’ definition of homebound, it is considered insufficient because it “offers no specific statement about the patient’s condition.”

The OIG further stated that Home Health Medicare Administrative Contractors (MACs) vary on whether they allow the use of checkboxes.  Some MACs allow the use of checkboxes only if narrative text is also included.

The OIG went on to discuss the fact that many certifying physicians did not include their printed or stamped name in addition to their signature and, where the signature was illegible, they could not determine the identity of the certifying physician.  Therefore, best practices should include a typed or stamped name under the signature.

Even though the face-to-face documentation must come from the patient’s certifying physician, it is the home health agency that will be held financially accountable if the appropriate documentation is not maintained.  Home health agencies should use compliance policies and procedures to monitor the appropriateness of the face-to-face documentation being provided by the certifying physicians and provide education where necessary.

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