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CMS to Reopen Home Health Claims Denied Based on Face-to-Face Requirements

CMS has announced that it is requiring Medicare to reopen claims that contractors denied because Home Health Agencies (“HHA”) allegedly did not comply with “Face-to-Face” encounter requirements put in place by the Patient Protection and Affordable Care Act (“ACA”), or Health Reform legislation.

The Face-to-Face encounter rules require that the physician certifying the patient’s need for home health care must have seen the patient “face-to-face” in order for Medicare to pay for a home healthcare episode. This encounter must take place either 90 days before the home health episode, or within 30 days of the beginning of home health care.

Providers brought to CMS’ attention that contractors were inappropriately denying claims based on the face-to-face requirement in two situations following an acute or post-acute stay:

•- When the HHA used a single form for the plan of care and the certification using a single signature by a “community physician” who assumed the oversight of care for an HHA patient, and

•- When the physician who cared for the patient in the acute or post-acute setting is the certifying physician and has signed the face-to-face encounter attestation.

Typically the forms HHAs submit to Medicare have only one signature line for, potentially, two physicians-often the certifying physician will be different than the community physician overseeing a patient’s care in an HHA. The physician who cared for a patient in an acute or post-acute setting may certify the patient’s eligibility for home health services, provide face-to-face encounter documentation, and initiate a plan of care, while a community physician will assume responsibility of the patient’s ongoing home health care and make changes and updates to the plan of care as needed.

Often, the HHA will have one physician sign the plan of care for a patient as well as the no-longer-required CMS-485 form, while another physician provides face-to-face encounter documentation in the form of an addendum to the CMS-485 form. In this case, CMS has determined that the physician who signed the plan of care is the physician responsible for oversight of the patient’s home health care.

CMS has also identified situations in which the physician who signs the face-to-face documentation does not name the community physician taking oversight of the home care. CMS does not require that the face-to-face-signing physician provide specific documentation to the contractor regarding the transition to a different physician for home health oversight.

As a result, CMS is requiring all contractors reopen any claims denied for not having met face-to-face requirement, upon request of providers. Contractors are then required to assess whether the claims meet the face-to-face requirements. Even if a contractor determines that a certain claim meets these requirements, the contractor must subsequently perform a complete and full review of all Medicare requirements in order to determine that the claim is payable. If you are a home health agency or provider and believe that you have been subject to inappropriately denied claims that should be payable because the claims met the face-to-face encounter requirements, please contact a Wachler and Associates, P.C. attorney by email or by phone at 248-544-0888.