Why isn't Mary Receiving the Home Health Care Her Physician Ordered?

Published 11/13/2018

Mary is a Medicare beneficiary seeking home health services following an inpatient stay. Unfortunately, Mary's physicians are not complying with Medicare requirements. Therefore, Medicare has denied her claims. The home health agency (HHA) is unwilling to continue to provide services without Medicare reimbursement.

Mary was in the hospital with a hospitalist responsible for her care. The hospitalist worked diligently to diagnose and treat her illness or injury. Mary's condition improved and she is now able to go home. The hospitalist determines Mary will be confined to her home and will need intermittent skilled nursing care and physical therapy. The hospitalist and staff made arrangements with the local HHA to treat Mary and provide her the skilled care and physical therapy she needs. The hospitalist transfers Mary's care to her primary care physician.
The HHA needs certain pieces of information to bill Medicare for the home health services provided. The requirements are listed in the CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30. The HHA sends a request to both the hospitalist and the primary care physician for additional information.

Unfortunately, neither the hospitalist nor the primary care physician replies to the request for documentation. Medicare will deny the home health claim or recoup any payment made when the home health agency is not able to provide the necessary documentation. The HHA is no longer able to care for Mary since there will be no Medicare payment.

The primary care physician believes that Mary is receiving skilled nursing services and physical therapy to assist her in recovering from her illness. However, Mary is not receiving care and that neglect will be apparent at the next in-person visit.

To ensure Mary is able to access her Medicare benefits and to assist the HHA in providing the services that you and the hospitalist have ordered for Mary, please verify Mary's medical record contains the necessary information and provide this to the HHA when requested.

Unfortunately, the HHA may determine not to take referrals from the individual physicians in the future if they continue to experience difficulty in gathering the documentation to support Medicare payment for the services.

Action to Take:

  • Verify Mary's medical record both in the inpatient facility and the physician's office contain the necessary information
  • Validate Mary is unable to leave her home without great difficulty, and describe her challenges and any accommodation needed
  • Describe Mary's specific needs, the treatment and goals for Mary and which professional will go into home
  • Verify Mary has had a face-to-face visit within the 90 day period prior to the start of home health or within 30 days after the start of the home health, and is related to the reason for home health
  • Share the medical record with the HHA when requested
  • See the CMS Internet Only Manual (IOM) Publication 100-02, Benefit Policy Manual, Chapter 7, Section 30 (PDF) for more information

To assist the HHA in providing and receiving appropriate reimbursement for Mary (and other patients), please submit the appropriate documentation when requested to do so. This will ensure the HHA can receive appropriate Medicare payment and your patient's care will not be interrupted or discontinued.

To find more information, please see the Home Health Medicare Administrative Contractor Websites. 

CGS Administration — Home Health Face-to-Face Documentation

Palmetto GBA — Home Health Latest Articles

NGS — Referring the Medicare Beneficiary to Home Health Services

This document was developed through the A/B Medicare Administrative Contractor Home Health and Hospice Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

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