OIG Reports Limited Compliance with Face-to-Face Certification Requirement for Home Health


The OIG recently released a report summarizing the details of its study regarding compliance with the requirement that physicians (or certain practitioners working with them) who certify beneficiaries as eligible for Medicare home health services must, as a condition of payment for home health services, appropriately document the occurrence of face-to-face encounters with those beneficiaries. After reviewing 644 face-to-face encounter documents, interviewing the four Home Health and Hospice Medicare Administrative Contractors (MACs) to determine how such MACs ensure compliance with the face-to-face requirement, and reviewing CMS guidance on how to monitor the requirement, the OIG determined that close to one-third of home health claims that required face-to-face encounters did not have documentation adequate to meet Medicare requirements, amounting to $2 billion in payments that should not have been made, according to the OIG.

Each sixty-day episode of home health care provided to a beneficiary, for which Medicare pays a standard payment, requires a physician to certify the beneficiary's need for such service, and prior to the first episode of care, a physician must certify the occurrence of a face-to-face encounter with such beneficiary. While CMS permits the use of a standard form to complete the required documentation, the certifying physician must actually complete and sign the documentation himself or herself and not simply sign documentation prepared by the home health agency, even if the encounter was completed by a physician who cared for the patient in an acute-care or post-acute-care facility or a qualified non-physician practitioner.

The OIG found that 32 percent of the documentation reviewed for initial home health certifications either had no face-to-face documents or had face-to-face documents that lacked at least one of the required elements, such as the date of the encounter, the certifying physician's signature, or the date of the physician's signature. Additionally, among other findings, the OIG noted that a brief narrative of the patient's condition that supports home bound status, which may be completed in as little as three sentences, was inconsistently completed and included general language about homebound status without specific references to the patient's actual condition.

In light of its review, the OIG recommended, and CMS agreed, that CMS should (1) consider requiring a standardized form to ensure that physicians include all required elements for face-to-face documentation; (2) educate physicians and communicate with them directly on the face-to-face requirement; and (3) work with MACs to ensure appropriate oversight of the requirement. A summary of the report is available here.

Reporter, Christina Gonzalez, Houston, + 1 713 276 7340, cagonzalez@kslaw.com.


Topics:  Beneficiaries, CMS, Healthcare, Healthcare Professionals, Home Health Care, MACs, Medicare, OIG, Physician Medicare Reimbursements, Required Documentation

Published In: Health Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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