Common Pitfalls in Home Health Audits

Payment for the Medicare home health benefit depends on a series of complex criteria that must be supported by documentation in the medical record, including a face-to-face encounter, homebound status, and need for skilled services. The requirements for home health documentation change frequently and give rise to some of the common pitfalls in home health audits.

First, the face-to-face encounter requirement requires that a qualified provider, usually the certifying physician, have an encounter with the beneficiary within a certain timeframe, for reasons related to the reason that the beneficiary requires home health, and properly document the beneficiary’s need for home health. Until 2015, the qualified provider was required to include a “brief narrative” supporting the need for home health. This requirement has since been dropped in favor of a more holistic review of the medical record, and the signature and organizational requirements have changed as well in recent years.

Second, the documentation must support that the beneficiary is homebound. Homebound status turns on a complex test. To qualify for homebound status, the beneficiary must: (1) because of illness or injury, need the aid of supportive devices, special transportation, or another person in order to leave their residence or have a condition such that leaving home is medically contraindicated; and (2) exhibit a normal inability to leave home and leaving home must require a considerable and taxing effort. Over time, CMS has adjusted language to tighten these requirements. Certain infrequent absences from the home, such as for religious services or doctor’s appointments, will not disqualify a beneficiary.

Third, the documentation must support that the beneficiary needs skilled services, such as physical therapy, speech-language pathology, or occupational therapy. These services constitute skilled therapy services when, because of the patient’s condition, they require the skills of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety. However, the specific requirements for each skilled service have shifted over time as well. For example, in the 2014 Jimmo settlement, Medicare agreed to cover physical therapy that was expected to improve a beneficiary’s condition as well as physical therapy that expected only to maintain a beneficiary’s condition or slow further deterioration.

As home health requirements shift over time, it is often important to pay specific attention to dates of service and apply the requirements that were in place on those dates of service. It is often equally important to ensure that the auditor is applying the correct criteria and is not denying claims inappropriately.

For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in Medicare and other rules and regulations that may have an impact on home health audits. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney  at 248-544-0888 or wapc@wachler.com.