Kusserow on Compliance: New guidance concerning HHA face-to-face encounters

Home health programs, which have been a high priority for Medicare and Medicaid, are intended to provide an alternative to institutional care for people with severe disabilities. The services provided by home health agencies (HHAs) are intended to be delivered in a beneficiary’s home. This approach accounts for more than $20 billion paid by Medicare on behalf of 3.4 million beneficiaries with another estimated $15 billon in outlays paid by Medicaid programs.

The Department of Justice (DOJ) and the Office of Inspector General (OIG) have found considerable evidence to confirm that home health is among the most vulnerable health care programs to fraud and abuse. The OIG recently found that as many as a quarter of all Medicare HHAs had submitted “questionable” bills. It also noted that that the Government Accountability Office (GAO) reported that 40 percent of all convictions initiated by a group of Medicaid fraud-control units were for home health. The OIG has identified numerous problems in personal care services that leave the program vulnerable to improper payments, abuse and fraud, and the failure of physicians who certify beneficiaries as eligible for Medicare home health services to conduct the requisite face-to-face encounters with the beneficiaries.

CMS has taken note of these problems and reported that last year the Comprehensive Error Rate Testing (CERT) program found that more than half of the home health claims were paid improperly. Of the 1308 CERT-reviewed claim lines in error, approximately 90 percent were found to have insufficient documentation errors. The majority of these errors were due to inadequate documentation supporting the face-to-face requirement set forth by the Home Health Prospective Payment System.

In response to this problem, CMS has been working on a voluntary paper clinical template that could be completed by physicians during their face-to-face examination of a Medicare patient. Physicians may voluntarily use the CMS template as a progress or clinic note as part of the patient medical record. The template functions as a “skip-template” where physicians complete only relevant sections for each patient. However, the template must contain all relevant information sufficient for billing at the appropriate evaluation and management code level. CMS has received numerous comments on the length of the template and how it makes it difficult for physicians or practitioners to complete the template. CMS reminded commenters three things in regard to the template:

  • The use of a template is voluntary and physicians/practitioners will not be required to use it.
  • Once a physician/practitioner completes the template, the resulting document is a progress note or office note that is part of the medical record for that patient. The note must contain all relevant information sufficient for patient care and sufficient for the physician/practitioner to bill for the appropriate level evaluation and management service.
  • The template is intended to be a “skip-template” where not all sections are relevant for all patients and therefore can be skipped.

CMS expressed interest from the public on how to improve the template to increase physicians/practitioners compliance with documenting the necessary clinical elements and possibly decrease the length of the template. In addition to developing a paper clinical template for documenting a home health face-to-face examination, CMS is developing an electronic clinical template.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.