Home Health Under the Audit Target Crosshairs Again

Home health providers never seem to be able to catch a break.

The long history of close attention being paid to them dates back to 2011 when the Centers for Medicare & Medicaid Services (CMS) established the requirement for documentation of a face-to-face encounter that included specific elements. That proved to be challenging for some physicians, with the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) finding in a 2014 audit that over 30 percent of audited encounters did not meet the requirements; this translated to an estimate that over $2 billion was overpaid to providers in 2012.

Then, in 2015, CMS changed the rules, no longer requiring a specific face-to-face form as long as the necessary information was in the patient’s medical record – as I addressed in this RACmonitor.com article. But despite this easing of rules, compliance remained a challenge. In 2016, CMS announced a Pre-Claim Review Demonstration Project in Illinois, Texas, and Florida, but that was halted in April 2017 after starting only in Illinois. The published results of the few months of those audits did shed some light on the situation. During the first month of audits, only about 40 percent of submitted claims were approved, but within three months, the approval rate approached 90 percent.  

But a month later, CMS announced the Review Choice Demonstration Project, offering “more flexibility and choice for providers, as well as risk-based changes to reward providers who show compliance with Medicare home health policies.” They expected to start this in December 2018, but as of Jan. 1, 2019, CMS has not received federal approval for initiation.

So as home health providers in Illinois, Ohio, North Carolina, Florida, and Texas await the start of this new demonstration project, and other states wonder if CMS will expand the program nationwide, CGS, one of the home health Medicare Administrative Contractors (MACs), has published the first-year results from its targeted probe-and-educate audits of home health claims in its Monthly Bulletin. And the results are not encouraging.

Of 160 home health agencies that were audited, only four were deemed to be compliant, with the remaining 156 moving on to round two. Of those 156, a total of 32 are going on to round two because they did not even respond to the record request from CGS. The most common denial reasons were lack of compliance with the face-to-face documentation requirements, followed by invalid initial certification, accounting for 25 and 13 percent of denials, respectively, with 11 percent of denials due to lack of medical records.

What should home care agencies do with this information? As with all denials of any claims, there should be an analysis to determine what could have been done to avoid them. It is rare that a patient starts home care services without having seen a physician in the recent past, so a copy of the progress note from that visit should always be obtained, even if a separate face-to-face form is used. The revised requirements for documentation of the patient’s homebound status, need for skilled nursing care, and certification allows all the details to be included in the home health plan of care prepared by the home care agency. In that case, the physician must simply review, sign, and date the plan of care. If the certifying physician is not the physician who will be following the patient in the community, the name of the community physician must be noted. And of course, if a request for records is received, it should not be ignored.

Some providers wait to act until they are audited, or until their MAC issues a notice. But the standards followed by CGS in its audit are national standards set by CMS themselves, so unlike a local coverage determination, wherein there may be regional differences, there should be no variation. CMS has undated their MLN Matters article on Certifying Home Care Services, SE1436, which should be used by every home care agency to guide their documentation and record-keeping; it also provided a flowchart that can be used to review records prior to submission to ensure that all the necessary elements are present.

As healthcare moves more toward community-based services, ensuring that our patients have access to skilled home care services will be even more crucial. When 97.5 percent of home care agencies do poorly on an audit, with many of those due to simple oversights, the scrutiny of agencies is sure to increase. 

Program Note: Register to listen to Dr. Ronald Hirsch every Monday on Monitor Mondays at 10-10:30 a.m. ET.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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