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Transcript for audio podcast: Limited Compliance With Medicare's Home Health Face-To-Face Requirement

From the Office of Inspector General of Department of Health and Human Services

[Joyce Greenleaf] I'm Joyce Greenleaf, the Regional Inspector General for the Office of Evaluation and Inspections in Boston. With me is program analyst Danielle Fletcher to talk about the face-to-face encounter requirement for home health agencies. Danielle, can you tell us about Medicare's face-to-face requirement?

[Danielle Fletcher] Yes. It requires physicians to physically see and evaluate patients for home health services, a face-to-face visit, not a phone call. The Affordable Care Act requires physicians to document these visits.

[Joyce Greenleaf] Why is this face-to-face visit required?

[Danielle Fletcher] Medicare has found a lot of fraud in home health. The expectation is that the face-to-face visits help prevent that fraud by ensuring the physicians see and assess the patient and document that visit and assessment.

[Joyce Greenleaf] Tell us a little more about the face-to-face requirement.

[Danielle Fletcher] Sure, Joyce. First of all, it's only required for the initial episode of home health services. Second, it must be related to the primary reason that the beneficiary needs home health care. And third, it must occur within 90 days before the start of home care or within 30 days after the care starts.

[Joyce Greenleaf] Anything else?

[Danielle Fletcher] Yes-the physician that certifies the need for home health care must complete and sign the face-to-face documentation.

[Joyce Greenleaf] What needs to be included in the documentation?

[Danielle Fletcher] The certifying physician must title, sign, and date the document. It must include a brief narrative that describes why the patient is homebound and the reason the skilled service is necessary for the treatment of the patient's illness or injury.

[Joyce Greenleaf] Okay, what did you find?

[Danielle Fletcher] Well, we looked at the documentation for a sample of Medicare claims. We found that about a third of home health claims did not meet these Medicare requirements. Those claims totaled $2 billion dollars in payments that Medicare should not have paid during our review period in 2012.

[Joyce Greenleaf] Wow that's an enormous loss to the Medicare program. Can you tell us what issues you found in that documentation?

[Danielle Fletcher] Ten percent of the claims didn't have any documentation and those claims totaled $605 million dollars. And of those that documents, about a quarter were missing at least one required element.

[Joyce Greenleaf] What else did you find?

[Danielle Fletcher] The documentation did not always appear to follow Medicare guidance for describing homebound status and the necessity for skilled services.

[Joyce Greenleaf] What do you mean, Danielle?

[Danielle Fletcher] For example, we saw the phrase "taxing effort to leave home" as the reason that the patient was homebound; half of those documents didn't list any other reason the patient was homebound. The phrase "taxing effort to leave home" is included in Medicare's definition of homebound, and so it doesn't really tell us anything specific about the patient's condition.

[Joyce Greenleaf] How does Medicare oversee the requirement?

[Danielle Fletcher] Well that's just it; the Medicare program doesn't really have a system in place to ensure that providers are meeting the face-to-face requirements.

[Joyce Greenleaf] Given your findings, what did you recommend?

[Danielle Fletcher] A couple of things. First, Medicare should consider using a standardized form so that all required information is included. Second, get the word out. Communicate with physicians about the face-to-face requirement. Finally, find some new ways to ensure that home health agencies are meeting the face-to-face requirement. CMS agreed with all of our recommendations.

[Joyce Greenleaf] Anything else we should know about the face-to-face requirements?

[Danielle Fletcher] Well, Medicare has plans to require a face-to-face visit for durable medical equipment, and it has postponed that implementation.

[Joyce Greenleaf] Why are they concerned about durable medical equipment?

[Danielle Fletcher] Well, just like home health, Medicare has a lot of concerns about fraud there.

[Joyce Greenleaf] Thank you, Danielle, for talking about your work on the face-to-face requirement.

[Danielle Fletcher] You're very welcome Joyce.


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