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Sense and reason prevail at CMS

July 16, 2014
by Bob Gatty
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It’s fascinating how the government works.

This past April, the Office of Inspector General (OIG) of the Department of Health and Human Services reported the results of an investigation revealing that Medicare paid some $2 billion in home healthcare claims for services not properly documented by certifying physicians.

The problem, the OIG said, was that physicians were failing to properly complete narratives from their required face-to-face encounters with patients explaining why the skilled service is necessary for the treatment of the patient’s illness or injury.

According to OIG program analyst Danielle Fletcher, about one-third of home health claims did not meet Medicare’s documentation requirements. “Those claims totaled $2 billion in payments that Medicare should not have paid during our review period of 2012,” Fletcher declared in an agency podcast reporting on the investigation.

Ten percent of the claims, totaling $605 million, had no documentation at all, and about 25 percent were missing at least one required element, she said, adding that documentation did not always meet Medicare requirements for describing homebound status and the need for skilled services.

In its report, the OIG said that Medicare should consider using a standardized form so that all required information is included. In addition, the OIG said that Medicare should communicate with physicians about the face-to-face requirement and find new ways to ensure that home health agencies meet that requirement. Fletcher said the Centers for Medicare & Medicaid Services (CMS) agreed with all of those recommendations.

On July 1, however, when CMS issued its proposed 2015 payment rule for home health care, cutting payments to home health agencies by 0.3 percent, it did an interesting thing. Rather than issuing a standardized form or stressing the need for the face-to-face discussion and subsequent documentation as the OIG recommended, it eased up on those requirements, to “foster greater efficiency, flexibility, payment accuracy and improved quality.”

Here’s what CMS says about that move:

“The Affordable Care Act (ACA) mandates that the certifying physician or allowed non-physician provider (NPP) must have a face-to-face encounter with the beneficiary before he or she certifies the beneficiary’s eligibility for the home health benefit. Current regulations require the encounter occur within 90 days before care begins or up to 30 days after care began. Documentation of the encounter must include a narrative to explain why the clinical findings of the encounter support that the patient is homebound and in need of skilled services.

“In this rule, CMS is proposing three changes to the face-to-face encounter requirements. First, we are proposing to eliminate the narrative requirement currently in regulation. The certifying physician would still be required to certify that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility.

“Second, for medical review purposes, we are proposing to only consider medical records from the patient’s certifying physician or discharging facility in determining initial eligibility for the Medicare home health benefit.

“Lastly, we are proposing that the physician claim for certification/re-certification of eligibility for home health services (not the face-to-face encounter visit) be considered a non-covered service if the HHA [home health agency] claim was non-covered because the patient was ineligible for the home health benefit.”

CMS added that the face-to-face encounter requirement applies to the physician’s certification only, not recertification of eligibility for subsequent episodes.

Interestingly, the proposed rule followed by less than one month the June 5 filing of a lawsuit by the National Association for Home Care & Hospice (NAHC), alleging that the CMS denied numerous payment claims because physicians did not supply sufficient paperwork, such as the required narrative, not because the physicians had failed to see patients or certify them for payment.

The regulation, declared Andrea Devoti, chairman of the NAHC Board of Directors, “has created a crisis and is denying the infirm elderly the care that they need, which is why we had no choice but to take our case to federal court.”

So the bottom line now is that the certification and face-to-face discussions required by the ACA still stand, but physicians no longer will be required to write a descriptive explanation as to why a patient is homebound and, therefore, needs in-home care. In effect, the physician or the NPP is being given some credit for using sound medical judgment in making his or her certification.

Seems like a good result, especially if that paperwork requirement had caused a “dramatic upsurge in in retroactive denials of patient claims for payments,” as NAHC had contended.

Comments on the proposal are due Sept. 2.

Related article: Home health payments reduced $58 million under CMS proposal