Home Care Group Plans CMS Lawsuit Over Home Health Rule

A home care industry trade group is exploring the possibility of filing suit against the Centers for Medicare & Medicaid Services if it goes forward with implementing home health care face-to-face requirements under a health care reform provision.

The National Association for Home Care & Hospice argues that more guidance and clarity is needed from CMS for the new requirements stemming from the Affordable Care Act, citing frustration among providers who have death with denied face-to-face meetings.

The NAHC’s Board of Directors has approved moving forward with filing a lawsuit challenging Medicare’s implementation of the requirement for home health patients to have a face-to-face encounter with a physician in order to qualify for coverage, Val Halamandaris, the group’s president, announced at the recent March on Washington and Annual Policy Conference. 

More than 80% of claim denials for Medicare home health benefits relate to the face-to-face requirements, according to statistics released by Medicare Administrative Contractors. Home health agencies have reported experiencing a “significant” increase in retroactive claim denials since CMS issued the rule and guidance on those requirements, according to NAHC. 

Medicare is denying claims based on allegations that patients seeking the benefits don’t have a sufficient “physician narrative” supporting their home-bound status and need for at-home skilled care.

“When the vast majority of claim denials involve documentation insufficiency, it should be apparent that something is seriously wrong with Medicare’s documentation guidance,” said Bill Dombi, NAHC’s Vice President for Law, in a statement. “Home health agencies are desperately trying to submit claims with compliant documentation. They have no interest in suffering the losses triggered by retroactive claim denials.” 

The lawsuit is expected to get filed in the federal District Court in Washington, D.C. in April and present three legal causes of action, including that Medicare overstepped its authority under the ACA by requiring the physician narratives on home bound and skilled care need. The healthcare law only requires physicians to document that an encounter occurred, the trade group notes. 

Another point the lawsuit will likely include is CMS’ obligation to establish standards for compliance that can be adequately understood and applied by physicians and home health agencies, considering the federal agency has the power to require narratives. 

Lastly, the lawsuit will claim that Medicare cannot deny a claim based on an allegation of insufficient documentation unless it reviews the patient’s entire record.

“Any alleged deficiency in the required brief narrative from the physician should lead to a comprehensive review of the entire patient record to determine if the patient meets home bound and skilled care requirements,” NAHC argues.

Written by Alyssa Gerace

Alyssa Gerace