Hospital Group Opposes Proposed CMS Home Health Audit Rules

Of the various provisions outlined in the Centers for Medicare & Medicaid Services’ (CMS) 2015 proposed rule for the home health prospective payment system, just one section regarding new audit procedures for home health agencies has garnered opposition from a national hospital trade group.

Specifically, the American Hospital Association (AHA) strongly opposes CMS’s proposal to establish new audit procedures that would base audits of one provider on the medical records of another provider, according to a letter sent by AHA Executive Vice President Rick Pollack to CMS Administrator Marilyn Tavenner.

“While we understand the intent of the audit provisions in this proposed rule—to encourage physicians to engage in timely and well-documented assessments of [home health] eligibility—CMS’s mix-and-match audit approach is inappropriate and would place HH providers at risk of a denial based on the documentation of individuals outside of their oversight and control,” Pollack wrote.


To avoid violating providers’ accountability boundaries, AHA urges CMS to withdraw three audit-related proposals regarding home health medical necessity, physician audits and a proposed new physician condition of payment.

Under the home health medical necessity audits, if the certifying physician’s record lacks sufficient documentation of eligibility for Medicare home health services, payment would not be rendered to the home health agency.

“The AHA does not support CMS’s proposal to base Medicare HH medical necessity audits on ‘only the medical record for the patient from the certifying physician or the acute/post-acute facility,'” Pollack writes. “Rather, audits of HH medical necessity should be based on the documentation found in HH agencies’ medical records.”


Likewise, the AHA also opposes the proposal to base payment for physician claims for certifications and re-certficiations of home health eligibility on the status of a separate provider’s claim.

“Any audit of physician services should be based on the claims and medical records of that physician; therefore, we urge CMS to withdraw this proposal, as well,” the letter states.

Additionally, in a related provision, the proposed CMS rule also discusses a new Part B physician condition of payment. Under this proposal, a physician’s claim for certification/re-certification of home health eligibility would be linked to the payment status of the corresponding home health claim.

In the event a home health claim is denied due to an incomplete certification, or insufficient documentation to support the claim’s eligibility for Medicare services, then the related physician claim would also be denied.

An area of concern regarding this proposal is that the rule does not explain when and how a home health denial would trigger a denial of and payment recoupment from the related physician, AHA notes in the letter.

“If the [CMS] elects to proceed with a regulatory approval, it should do so through the physician fee schedule to ensure that all stakeholders, especially physicians, are aware of this proposed change and have the opportunity to submit public comments,” Pollack writes.

Also of chief concern for AHA is that the proposed new audit relationship that links physician payment and audits to home health claims may discourage some physicians from assessing and certifying patients for home health eligibility in efforts to avoid vulnerability for audit denials.

“Should this occur, beneficiary access to HH services could be negatively impacted,” states the letter. “In addition, any progress made since 2011 to increase physician compliance with this policy may be stalled or reversed.”

The proposed rule, which was published in the Federal Register July 7, is soliciting comments until September 2.

View the AHA letter here.

Written by Jason Oliva

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