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Medicaid Update for Home Health Care Agencies

Feb 3, 2016

The Centers for Medicare & Medicaid Services (“CMS”) recently published a revision to their final rule regarding the provision of Home Health Care Services for Medicaid eligible beneficiaries. A similar revision has already been in place for Medicare beneficiaries.

According to this revision, Medicaid patients seeking authorization for home health services must now have a documented “face to face encounter with their physician either 90 days prior or no later than 30 days after the onset of home health care services.” This is for straight Medicaid beneficiaries and currently does not apply to Medicaid Managed Care beneficiaries.

This will have a direct effect on the intake, coordinating and clinical departments within home health care agencies. These departments typically work synergistically both prior to and during the onset and provision of home health care services to their patients.

Prior to the onset of care, typically, the intake department staff is responsible for obtaining and confirming all of the patient’s demographic and insurance eligibility information. The Coordinating Department staff then must identify and schedule a home health aide to service this patient based on the patient’s needs and geographic location. The clinical department staff is responsible for having a registered nurse assess the patient, identify the patient’s medical needs and develop a plan of care for the home health aide to follow while onsite at the patient’s home and in accordance with the insurance payer’s authorized hours/days/units of service. All of these functions are imperative to the onset, provision and respective billing and reimbursement for home health care services.

This CMS update will now ensure that home health care agencies take/have an additional step in place prior to the onset of care. That step is to ensure Medicaid beneficiaries have had their face to face encounter with their physician and to obtain written proof of this encounter (physician’s note/order) to add to the patient’s file. This should be done to keep a proper audit trail and to utilize, if necessary, for billing rejections/denials to reduce exposure to providing unauthorized care and subsequent bad-debt write-off.


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Steven Bisciello

Steven Bisciello is a Health Care Services Group, Partner experienced in revenue enhancement programs, health care litigation, compliance and physician practice management.

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