What is the Medicare Face-to-Face Home Health Requirement?

A controversial Medicare requirement continues to cause unrest in the Home Care industry and has recently been the focus of a federal lawsuit. The Medicare “Face-to-Face” Home Health requirement is a hot topic of conversation within the industry, as it is a regulation that directly affects physicians and those in the medical field, home care and hospice agencies and those requesting home health Medicare benefits and reimbursement.

What is the Medicare Face-to-Face Home Health Requirement?

The Medicare Face-to-Face Home Health requirement, a regulation in accordance with the Affordable Care Act, requires an in-person physician’s visit in order to certify a patient’s home health benefit, according to cms.gov. This means that under the law, a physician must assess and document a patient’s condition and provide a brief narrative verifying their eligibility for the home health Medicare benefit. While revisions to this requirement were later made, some important initial provisions of this requirement are as follows:

  • A physician or allowed non-physician practitioner (NPP) must document having met with a patient face-to-face and certify them for Medicare home health benefits
  • The certification for service eligibility must be related to physician’s assessment of a patient’s clinical condition
  • Patients beginning care on or after January 1, 2011 require this documentation on their certification
  • Visit must occur within 90 days prior to, or within 30 days after beginning of home health care 

Who has been impacted by this requirement?

Both physicians and home healthcare agencies have not been in agreement with the face-to-face requirement. “This new requirement caused widespread chaos, spurred a physician rebellion, and in the end deprived many seniors from receiving the care to which they were entitled under the Medicare home health benefit,” said the National Association for Home Care and Hospice (NAHC) in a January 2015 press release.

In response to this public outrage, the Centers for Medicare and Medicaid Services (CMS) revised its requirement, removing the written narrative portion of the requirement.  Unsatisfied with this requirement change, NAHC then filed a lawsuit in federal court seeking millions in denied claims dating from 2011 to 2014 under that provision of the requirement, according to its January press release. NAHC had previously requested CMS to pay “some $250 million owed to home health agencies for care they gave to Medicare patients between 2011-2014”. This request was denied, resulting in the lawsuit moving up to federal court.

What Now?

The federal lawsuit seeking compensation for denied claims has proceeded to the next stages, as a federal district court struck down the government’s requests to dismiss the case in January, according to the NAHC press release.  This situation is fluid and worth monitoring, with the results of the federal lawsuit potentially making a further impact in the home care industry and spurring more conversation on the topic.  Recently the federal court ruled in favor of Medicare while restricting the scope of the face to face narrative.

At Manchester Specialty Programs, we understand how difficult it can be to navigate regulations while providing quality home care and hospice services.  We deliver specialty insurance programs offering all the insurance coverage you need to operate in one easy to access program.  Part of our product line includes regulatory audit coverage for the emerging risk and exposure of billing and working with Medicare.  For more information, you or your local insurance broker can call us today at 1-855-972-9399.