HHA Payment Denials for Home Health Face to Face Requirements Will Get Another Look

Last year, CMS gave home health agencies extra time to comply with the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) over concerns that some providers may need additional time to establish operational protocols necessary to comply with the new face to face encounter requirements. Although CMS gave extra time during the first quarter of calendar year (CY) 2011 for home health agencies and physicians who order home health services to collaborate and establish internal processes to ensure compliance, there are still some kinks in the process and many providers are experiencing problems with being reimbursed properly when home health care follows an acute or post-acute stay.

The home health face to face requirement was established by Section 6407 of PPACA for the certification of eligibility for Medicare home health services. Per the requirement, the certifying physician must document that he or she, or a non-physician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care. Home health agencies must have documentation of that encounter on certifications for patients with starts of care on or after January 1, 2011.

CMS has revealed that it has been brought to their attention that some contractors are denying payment for patients who use home health services following an acute or post-acute stay when:

  • (1) the home health agency uses a single form (for example, the CMS-485 form) for the plan of care and the certification, using a single signature by the community physician who assumes oversight of the patient’s home healthcare, and
  •  (2) when the physician who cared for the patient in the acute or post-acute setting is the certifying physician and has provided and signed attached documentation of the face-to-face encounter.

CMS does not require that a specific form be used for the certification or the plan of care.  However, many providers have chosen to use the no-longer-required CMS-485 form as a means of satisfying the plan of care and the certification requirements. Typically, CMS notes, providers who use this form attach the face-to-face encounter documentation to the CMS-485 as an addendum. This form contains only one physician signature line for both the plan of care and the certification of eligibility. This poses a problem because in many cases, these are two different physicians.

In the case of patients admitted to home health following an acute or post-acute stay, CMS points out that the Benefit Policy Manual (BPM) language allows for one physician to sign the certification and face-to-face documentation, while a different physician can sign the plan of care. Home health agencies must still ensure that the face-to-face encounter documentation and the CMS-485 form together satisfy all of the certification and plan of care content requirements which are defined in Chapter 7 Section 30 of the BPM.

According to CMS, Medicare contractors will accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the certification, face-to-face encounter, and plan of care requirements. CMS has clarified that, in this scenario, the certifying physician is the acute or post-acute physician, has initiated content on the CMS-485, and has completed and signed the face-to-face encounter documentation, and the physician is the one who signs the CMS-485 assumes care for the patient’s home healthcare.

CMS has also found that that some contractors are denying claims because there is a failure of the acute or post-acute physician to identify the community physician who will be taking over the care for the patient. However, CMS has not mandated that the acute or post-acute physician must follow a specific documentation protocol to hand-off a patient to the community physician.

Because of these issues, CMS has instructed contractors to reopen and determine if face-to-face requirements have been met, due to their meeting the criteria described in the instruction described above. A complete and full review must then be performed to determine if payment should be made. So now is the time to take a look back through any denied claims to see if this is a possibility. It does not mean that there will be an automatic payment of the claim, but it does mean that if it meets these requirements, it will be paid.