Case study 2 6176

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Case #2: Home HealthBACKGROUNDThe Patient Protection and Affordable Care Act (ACA) requires that physicians (or certain practitioners working with them) who certify beneficiaries as eligible for Medicare home health services document—as a condition of payment for home health services—that face-to-face encounters with those beneficiaries occurred. This study (1) determined the extent to which physicians who certified home health care documented the face-to-face encounters, (2) described the nature of face-to-face documentation, and (3) assessed the Centers for Medicare and Medicaid Services’ (CMS) oversight of the face-to-face requirement.

HOW WE DID THIS STUDYWe reviewed 644 face-to-face encounter documents to analyze the extent to which the documents confirmed encounters and contained the required elements. We interviewed the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to describe how they ensure that home health agencies met the face-to-face encounter requirements. We also reviewed guidance documents and policies from CMS or the HH MACs about monitoring the face-to-face requirement.

WHAT WE FOUNDFor 32 percent of home health claims that required face-to-face encounters, the documentation did not meet Medicare requirements, resulting in $2 billion in payments that should not have been made. Furthermore, physicians inconsistently completed the narrative portion of the face-to-face documentation. Some face-to-face documents provide information that, although not required by Medicare, could be useful, such as a printed name for the physician and a list of the home health services needed. CMS oversight of the face-to-face requirement is minimal.QUESTIONSWhat is home health care and the types of services they provide?How are home health agencies paid and what services are covered?What is the purpose of the Medicare Home Health Face-to-Face requirement?What are some solution’s CMS should implement to ensure that all patients that need a face-to-face encounter receive one?