Compliance TODAY October 2013 A PUBLICATION OF THE HEALTH CARE - PDF document

Compliance TODAY October 2013 A PUBLICATION OF THE HEALTH CARE COMPLIANCE ASSOCIATION WWW . HCCA - INFO . ORG Why compliance Why compliance matters to the matters to the enforcement enforcement community community Loretta Lynch Loretta Lynch U.S. Attorney, Eastern U.S. Attorney, Eastern District of New York District of New York See page 16 See page 16 27 35 41 47 Medicaid Sunshine Act reporting: OIG issues Be part of vs. Medicare Minimizing updated guidance the solution: claims audit appeals: consulting and on exclusion: Stop medical A road less clear royalty payment What it means identity risks for providers fraud Cornelia M. Dorfschmid and Lisa Shuman Stephanie J. Kravetz Lester J. Perling Marita Janiga This article, published in Compliance Today , appears here with permission from the Health Care Compliance Association. Call HCCA at 888-580-8373 with reprint requests.

by Kristen P. McDonald, Esq., Lindsey Lonergan, Esq., and Krunal Shah Face-to-face requirements: What pitfalls lie ahead for home health agencies? » The long-awaited rule on home health face-to-face encounters has been published. » OIG recently indicated its intent to focus on the home health industry. » Home health agencies can learn from the pitfalls other providers have experienced with the face-to-face requirements. » Thorough documentation is required to ensure compliance with both the technical and medical necessity elements of the face-to-face encounter. » Compliance programs, including training, should be updated to refmect the face-to-face requirements. which summarizes the OIG’s activi- Kristen P. McDonald (kmcdonald@jonesday.com) is a Partner and ties for the upcoming fjscal year, the Lindsey Lonergan (llonergan@jonesday.com) is an Associate in the Health OIG intends to analyze the extent to Care and Life Sciences group at Jones Day in Atlanta. Krunal Shah was a which HHAs are complying with the 2013 Summer Associate in the Atlanta Jones Day offjce. face-to-face encounter requirements. I n November 2012, the Centers for Medicare In light of the government’s ongoing & Medicaid Services (CMS) issued a long- focus on fraud and abuse activities awaited fjnal rule, which clarifjed statutory in the healthcare industry, as well as McDonald requirements that physicians must follow to the OIG’s intent to focus specifjcally certify patients as eligible for the Medicare on HHAs in this upcoming year, it is home health benefjt. 1 In the newly promul- vital that HHAs are knowledgeable gated rule, physicians are required to complete about the requirements of face-to-face face-to-face encounters with each home health encounters and develop compliance patient at regular intervals and assess the measures to respond effectively to patient’s eligibility under Medicare’s complex those requirements. medical necessity guidelines. 2 The face-to-face encounter rule and the procedures home health fundamental requirements Lonergan agencies (HHA) must develop to comply with The fjrst step to complying with the face-to-face encounter rule is to fully the rule are fraught with compliance and reim- Compliance Today October 2013 understand its technical require- bursement implications for the home health ments. 4 To certify a patient as eligible industry. Although challenging, compliance for home health services, physicians with this rule has become even more important are required to certify that: as the Offjce of the Inspector General (OIG) · recently announced its intent to focus its review home health services are (or were) efforts on face-to-face encounters by HHAs. 3 needed because the patient is As noted in the OIG’s Work Plan for 2013, (or was) confjned to the home; Shah 58 www.hcca-info.org 888-580-8373

· the patient needs (or needed) skilled ser- other segments of the healthcare indus- vices on an intermittent basis; try. Indeed, hospice providers have been · a plan of care has been established and is required to complete face-to-face encounters periodically reviewed by a physician, and to recertify patients for hospice services since · January 1, 2011. 7 Similar to the face-to-face the services are (or were) furnished while requirements now imposed on HHAs, CMS the patient is (or was) under the care of a requires that hospices meet specifjc require- physician. ments when conducting and documenting face-to-face encounters. The Medicare Benefjt Furthermore, as of January 1, 2011, Policy Manual requires that a hospice physi- Medicare requires that a certifying physician document that the physician, or an allowed cian or hospice nurse practitioner must have non-physician practitioner (NPP), had a face- a face-to-face encounter with the benefjciary to-face encounter with the individual seeking within 30 days of the individual’s third benefjt home health services. 5 Allowable non-phy- period, and up to 30 days prior to every subse- sician practitioners quent benefjt period. include a certifjed The physician or nurse-midwife, a nurse practitioner is Most notably, physician assistant, required to document hospice providers have or a nurse practitio- the specifjc clinical ner or clinical nurse fjndings found in that experienced an uptick in specialist working encounter, and attest Medicare contractor audits in collaboration that these fjndings and resulting claims denials, with the physician. support a life expec- Once this tancy of six months often based on technical or less. 8 encounter occurs, fmaws in the face-to-face Because hospice the certifying physi- cian must personally providers have been documentation. reviewed for compli- compose a narra- tive describing the ance with face-to-face patient’s clinical requirements since condition as observed during the face-to-face the fjnal rule specifjc to hospice agencies was encounter and documenting how the patient’s fjnalized in November 2010, HHAs may learn clinical condition supports the patient’s home- valuable lessons from some of the pitfalls that bound status and need for skilled services. hospices have experienced with face-to-face The narrative must be signed by the certifying documentation. Most notably, hospice provid- physician, and the certifjcation must include ers have experienced an uptick in Medicare both the date when the physician or NPP saw contractor audits and resulting claims denials, Compliance Today October 2013 the patient and the date when the physician often based on technical fmaws in the face- signed his/her narrative. 6 to-face documentation. In many instances, hospice claims have been denied because of a Potential pitfalls of the face-to-face encounter lack of signature by the certifying physician Although the face-to-face encounter require- and/or the lack of a date on the certifjcation. ment is new to the home health industry, In other instances, hospice claims have been the face-to-face requirement is not new to denied because the narrative is not deemed 888-580-8373 www.hcca-info.org 59