On April 9, 2014, the US Department of Health and Human Services Office of the Inspector General’s (OIG) Office of Evaluation and Inspections (OEI) issued a report (OEI-01-12-00390) entitled “Limited Compliance With Medicare’s Home Health Face to Face Documentation Requirements.”

The Center for Medicare and Medicaid Services (“CMS”) requires physicians to physically see and evaluate patients for home health services. The Patient Protection and Affordable Care Act requires the physicians to document this face-to-face visit as a condition of payment. The face-to-face requirement was implemented to help prevent fraud in home health. The idea is that requiring physicians to document the specifics of a face-to-face visit with a Medicare beneficiary will help prevent fraud by ensuring the physician actually saw and assessed the beneficiary before certifying the patient as eligible for home health services.

To qualify for home health services a Medicare beneficiary must: (1) be homebound; (2) need intermittent skilled nursing care, physical therapy, speech therapy, or continuing occupational therapy; (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. Before a home health agency can receive payment from Medicare for home health services, a physician must certify the beneficiary’s need for the services.

The face-to-face visit is only required for the initial period of home health services. The visit must be related to the primary need for home health care and must be completed either 90 days before care begins or 60 days after care begins. The physician’s documentation of the face-to-face visit must include an appropriate title, the physician’s signature and relevant dates. It also must include a narrative describing why home health services are necessary.

The Department of Health and Human Services Office of Inspector General (the “OIG”) conducted a review of 644 face-to-face encounter documents to analyze the extent to which the documents confirmed encounters and contained the required elements. The OIG found that $2 billion worth of claims did not meet the requirements and should not have been paid. 10% of the claims reviewed did not include any documentation of the face-to-face visit at all. 25% of the claims that included documentation were missing at least one of the required elements. Furthermore, the required narratives were either missing or insufficient to accurately describe the patients need for home health services.

After analyzing the results of the review, the OIG made the following recommendations to CMS: (1) consider requiring a standardized form to ensure that all required information is included in the physician’s the face-to-face documentation; (2) communicate with physicians to assure their knowledge and understanding of the requirement; and (3) develop an oversight mechanism to ensure home health agencies are meeting the face-to-face requirement. Given that CMS agreed with all of the OIG’s recommendations, we are expecting CMS to issue further guidance on the face-to-face requirement for home health services in the near future.

Additionally, CMS has plans to implement a face-to-face requirement for durable medical equipment (“DME”) providers. Though CMS postponed implementation of the requirement for DME providers in September of 2013, CMS has since announced the requirement is forthcoming in 2014.