(January 9, 2017): As the Centers for Medicare and Medicaid Services (CMS) has announced, the alleged error rate associated with home health claims has risen from 17.3 % in FY 2013 to 51.38% in FY 2014 and 58.95% in FY 2015. In light of these increases, CMS has taken steps to address the home health claims error rate. Section 402(a)(1)(J) of the Social Security Amendments of 1967 authorizes the Secretary for the Department of Health and Human Services (HHS) to develop demonstration projects that:
“[D]evelop or demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by the Social Security Act.”
Consistent with this authority, on February 5, 2016, the Centers for Medicare and Medicaid Services (CMS) published notice in the Federal Register that it intended to collect information that would be used by the agency to serve as a:
“[B]aseline estimate of probable fraud in payments for home health care services in the fee-for-service Medicare program.” 42 U.S.C. 1395b-1(a)(1)(J).
On June 8, 2016, CMS announced in the Federal Register (81 Fed. Reg. 37598) that five states would be part of the new Pre-Claim Review Demonstration. These states included: Illinois, Florida, Texas Michigan and Massachusetts. While the program was implemented in Illinois on August 3, 2016, the rest of the implementation schedule was delayed due to a variety of implementation-related problems.
CMS has recently announced that the Pre-Claim Review Demonstration Project will be resumed and that it will be implemented in Florida on April 1, 2017. While no implementation dates have been announced yet for Texas and the remaining test states, Texas home health providers could conceivably be facing this program as early as May 1, 2017.
In addition to providing an overview of the home health Pre-Claim Review Demonstration Project, this article examines the primary reasons for claims denial identified so far by Illinois home health agencies. In this first article, we are focusing on the denial reasons associated with errors identified with face-to-face and plans of care / certification / recertification documentation.
I. What are Medicare’s Home Health Benefit Requirements?
To qualify for the Medicare Home Health benefit, under 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, a Medicare beneficiary must meet the following requirements:
- Be confined to the home at the time of services;
- Medicare considers the person homebound if:
- There exist a normal inability to leave the home, and
- Leaving home requires a considerable and taxing effort.
- Additionally, one of the following must also be true:
- Because of illness or injury, the person needs the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence; or
- The person has a condition such that leaving his or her home is medically contraindicated.
- Under the care of a physician;
- Receiving services under a plan of care established and periodically reviewed by a physician;
- Be in need of skilled services;
- Have a face-to-face encounter with an allowed provider type as mandated by the Affordable Care Act. This encounter must:
- Occur no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care; and be related to the primary reason the patient requires home health services and was performed by a physician or non-physician practitioner.
II. Primary Reasons for the Denial of Home Health Claims Identified:
Based on the claims submitted by home health agencies in Illinois thus far, the following reasons for denial have been cited by Palmetto when reviewing agencies’ home health claims:
[ezcol_1quarter]Denial Reason Code[/ezcol_1quarter] [ezcol_3quarter_end]Face-to-Face Errors[/ezcol_3quarter_end]
[ezcol_1quarter]HH01A[/ezcol_1quarter] [ezcol_3quarter_end]The physician certification was invalid since the required face-to-face encounter document was missing (actual clinical note for the face-to face encounter visit for admissions on or after 1/1/15, or the narrative for admissions on or after 4/1/11and before 1/1/15) Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1 and 30.5.1.2.[/ezcol_3quarter_end]
[ezcol_1quarter]HH01B[/ezcol_1quarter] [ezcol_3quarter_end]The physician certification was invalid since the required face-to-face encounter document was untimely and/or the certifying physician did not document the date of the encounter. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1.2[/ezcol_3quarter_end]
[ezcol_1quarter]HH01A[/ezcol_1quarter] [ezcol_3quarter_end]The physician certification was invalid since the face-to-face encounter was not performed by an approved practitioner. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.1.1[/ezcol_3quarter_end]
[ezcol_1quarter]HH01D[/ezcol_1quarter] [ezcol_3quarter_end]The physician certification was invalid since the required face-to-face encounter was not related to the primary reason for home health services. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.1.2[/ezcol_3quarter_end]
[ezcol_1quarter]Denial Reason Code[/ezcol_1quarter] [ezcol_3quarter_end]Plan of Care / Certification / Recertification[/ezcol_3quarter_end]
[ezcol_1quarter]HH02A[/ezcol_1quarter] [ezcol_3quarter_end]The Plan of Care was missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.[/ezcol_3quarter_end]
[ezcol_1quarter]HH02B[/ezcol_1quarter] [ezcol_3quarter_end]The content of the Plan of Care submitted was insufficient. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.1.[/ezcol_3quarter_end]
[ezcol_1quarter]HH02C[/ezcol_1quarter] [ezcol_3quarter_end]The Plan of Care submitted was not signed. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.3[/ezcol_3quarter_end]
[ezcol_1quarter]HH02I[/ezcol_1quarter] [ezcol_3quarter_end]The Plan of Care submitted was not signed timely by a qualified physician. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.2.4.[/ezcol_3quarter_end]|
[ezcol_1quarter]HH02D[/ezcol_1quarter] [ezcol_3quarter_end]Missing physician certification/recertification. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5[/ezcol_3quarter_end]
[ezcol_1quarter]HH02E[/ezcol_1quarter] [ezcol_3quarter_end]The physician certification/recertification submitted does not support skilled need. Documentation in the certifying physician's medical records and/or the acute/post- acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility.Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5 and 42CFR 424.22 (a) and (c).[/ezcol_3quarter_end]
[ezcol_1quarter]HH02F[/ezcol_1quarter] [ezcol_3quarter_end]The physician certification / recertification submitted does not support homebound status. Documentation in the certifying physician's medical records and/or the acute /post-acute care facility's medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. Refer to CMS IOM Publication 100- 02, Chapter 7, Section 30.5 and 42CFR 424.22 (a) and (c).[/ezcol_3quarter_end]
[ezcol_1quarter]HH02G[/ezcol_1quarter] [ezcol_3quarter_end]The physician recertification estimate of how much longer skilled services are required is missing. Refer to CMS IOM Publication 100-02, Chapter 7, Section 30.5.2.[/ezcol_3quarter_end]
[ezcol_1quarter]HH02H[/ezcol_1quarter] [ezcol_3quarter_end]The home health agency generated record contained relevant clinical information addressing the “confined to the home” (homebound) eligibility requirement, which was corroborated by the certifying physician or the acute/post-acute facility documentation, but was NOT signed and dated by the certifying physician. Please have the certifying physician sign and date the relevant HHA-generated information and resubmit. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.3.[/ezcol_3quarter_end]
[ezcol_1quarter]HH02J[/ezcol_1quarter] [ezcol_3quarter_end]The home health agency generated record contained relevant clinical information addressing the “need for skilled services” eligibility requirement, which was corroborated by the certifying physician or the acute/post-acute facility documentation, but was NOT signed and dated by the certifying physician. Please have the certifying physician sign and date the relevant HHA-generated information and resubmit. Refer to CMS IOM Publication 100-08, Chapter 6, Section 6.2.3.[/ezcol_3quarter_end]
III. Lessons to be Learned:
Home health agencies in Florida, Texas, Michigan and Massachusetts should carefully review the denial reasons outlined above and conduct internal audits of your home health claims documentation to determine whether your agency’s documentation is complete. The experiences of home health agencies in Illinois can be invaluable to your efforts to better ensure the full compliance of your agency with applicable statutory and regulatory requirements. In future installments of this article, we will examine other reasons for denial seen by Illinois home health agencies.
