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CMS agrees to drop narrative requirement for home health claims


By Virgil Dickson
Posted: July 1, 2014 - 7:45 pm ET
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The CMS plans to eliminate a regulatory hurdle that was intended to reduce fraud and abuse in Medicare home health claims but appeared to be stopping some elderly patients from getting care they need.

The policy change is included in a proposed Medicare payment rule for home health agencies for 2015. The CMS estimates that the home health providers would be paid $58 million dollars less under the revised payment system, a reduction of about 0.3%. In 2013, Medicare paid about 12,000 home health agencies $18 billion to provide services to 3.5 million beneficiaries.

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The Patient Protection and Affordable Care Act mandates that a Medicare beneficiary have a face-to-face encounter with a physician before the physician can certify that the patient is homebound and in need of skilled care. The CMS also required that the physicians provide a detailed narrative explaining the patient's circumstances.

Home health providers saw a dramatic upsurge in retroactive denials of claims because of inadequate narratives supporting the services, according to the National Association for Home Care & Hospice.

“No one knew what it would take to make the narratives sufficient,” said William Dombi, executive director of the National Council on Medicaid Home Care, an advocacy group affiliated with the NAHC.

HHS' Office of the Inspector General concluded in an April report that physicians in a third of sampled claims provided only a vague description of the patient or nothing at all. The OIG estimated the failures had led to $2 billion in improper payments.

The National Association for Home Care & Hospice, however, sued the CMS in early June arguing that the narrative requirement goes beyond the scope of the law's requirement that physicians document the face-to-face encounter.

The CMS noted in the draft rule issued Tuesday that the agency has received many complaints about the narrative requirement and proposed eliminating it to simplify the face-to-face encounter regulations and reduce the burden on home health agencies and physicians.

The physician would still be required to document the encounter to certify the patient's eligibility.

Follow Virgil Dickson on Twitter: @MHvdickson


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