OIG: $2 Billion in Home Health Service Claims Should Not Have Been Paid
A review of Medicare home health services by the Department of Health and Human Services’ Office of Inspector General has found that 32 percent of claims did not document the required face-to-face encounters, resulting in $2 billion in payments that should not have been made. In addition, OIG concludes that oversight of the face-to-face requirement by the Centers for Medicare and Medicaid Services is minimal.
A review of Medicare home health services by the Department of Health and Human Services' Office of Inspector General has found that 32 percent of claims did not document the required face-to-face encounters, resulting in $2 billion in payments that should not have been made. In addition, OIG concludes that oversight of the face-to-face requirement by the Centers for Medicare and Medicaid Services is minimal.
"CMS does not have a specific program to oversee compliance with the requirement for face-to-face documentation," states the OIG report. "Instead, it reviews the documentation when it conducts a medical record review as part of its general effort to deter and detect home health fraud."
Under the Affordable Care Act, as a condition of payment for home health services, physicians and certain practitioners working with them are required to certify that face-to-face encounters with beneficiaries actually occurred. Physicians use a standard form to document the visit and must actually complete the documentation. However, OIG reviewed 644 face-to-face encounter documents to analyze the extent to which the documents confirmed encounters and contained the required elements, and discovered that nearly a third either had no face-to-face documents or had face-to-face documents that lacked at least one of the required elements.
In addition, OIG discovered that physicians inconsistently completed the narrative portion of the face-to-face documentation. At the same time, the report commented that while some face-to-face documents provide information not required by Medicare, this information could be useful, including a printed name for the physician and a list of the home health services needed.
OIG in the report recommends that CMS consider requiring a standardized form to ensure that physicians include all elements required for the face-to-face documentation, develop a specific strategy to communicate directly with physicians about the face-to-face requirement, and develop other oversight mechanisms for the face-to-face requirement. CMS concurred with all of OIG's recommendations.
"CMS does not have a specific program to oversee compliance with the requirement for face-to-face documentation," states the OIG report. "Instead, it reviews the documentation when it conducts a medical record review as part of its general effort to deter and detect home health fraud."
Under the Affordable Care Act, as a condition of payment for home health services, physicians and certain practitioners working with them are required to certify that face-to-face encounters with beneficiaries actually occurred. Physicians use a standard form to document the visit and must actually complete the documentation. However, OIG reviewed 644 face-to-face encounter documents to analyze the extent to which the documents confirmed encounters and contained the required elements, and discovered that nearly a third either had no face-to-face documents or had face-to-face documents that lacked at least one of the required elements.
In addition, OIG discovered that physicians inconsistently completed the narrative portion of the face-to-face documentation. At the same time, the report commented that while some face-to-face documents provide information not required by Medicare, this information could be useful, including a printed name for the physician and a list of the home health services needed.
OIG in the report recommends that CMS consider requiring a standardized form to ensure that physicians include all elements required for the face-to-face documentation, develop a specific strategy to communicate directly with physicians about the face-to-face requirement, and develop other oversight mechanisms for the face-to-face requirement. CMS concurred with all of OIG's recommendations.
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