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Time to “Face” The Risks

In 2011, the U.S. Centers for Medicare and Medicaid Services (“CMS”), as part of the reform instituted by the Affordable Care Act, required that home health agencies and hospice patients receive a face-to-face visit (at specified time periods) by a physician or nurse practitioner to ensure that they continue to meet Medicare and Medicaid eligibility criteria.

As detailed earlier this week, the OIG, DOJ, and HHS are heavily targeting hospice care providers through audits and investigations. One of the biggest areas of risk for hospice providers are these face-to-face visits, as failure to conduct and thoroughly document them can lead to inappropriate recertification and eligibility, which results in overpayments that must be returned to the government. In a recent report, the OIG shared information from its investigation of home health agencies’ face-to-face documentation.  The OIG noted that 32% of the home health claims did not have the requisite or complete face-to-face encounter documentation, resulting in $2 billion in improper claims and overpayments.

Hospice providers must be well-versed in the requirements of the face-to-face visits and ensure strict compliance with its provisions. For Medicare reimbursement, the face-to-face encounter must occur no more than 30 calendar days prior to the 3rd benefit period recertification, and no more than 30 calendar days prior to every subsequent recertification thereafter (there are, in some instances, different requirements for exceptional circumstances). The rule contains detailed attestation and signature requirements. Although the Kentucky Medicaid recertification timing requirement is different from the Medicare rule, Kentucky Medicaid is ignoring that rule and applying the Medicare rule. Thus, the timing requirement is a complicated and tricky legal issue for Medicaid reimbursement.

Hospice care providers should take a look at their current face-to-face documentation policies and procedures and contact a health care attorney if there are any questions about the validity or thoroughness of policies and procedures. You can be sure that if your organization is audited, patients’ eligibility will be examined and an auditor will want to review the documentation on face-to-face visits.

This article is intended as a summary of newly enacted federal and state law and does not constitute legal advice.

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