Home Health Providers Make Headway in Avoiding CMS Denials

Unclear filing guidelines for Centers for Medicare & Medicaid Services’ (CMS) documents are costing home health care providers billions of dollars a year, a recent report shows.

Thirty-two percent of home health claims did not have the requisite or complete face-to-face encounter documentation, which resulted in $2 billion in payments that should not have been made between 2011 and 2012, the 2014 Office of Inspector General (OIG) report finds.

In 2012, 98% of beneficiaries met Medicare coverage requirements for home health services. However, OIG also found that home health agencies (HHAs) submitted 22% of claims in error because services were not medically necessary, or claims were coded inaccurately, resulting in $432 million in improper Medicare payments.


“CMS has really taken a stringent approach,” said Sharon M. Litwin, senior managing partner with 5 Star Consultants, LLC. “When reviewers look at clinical records there are so many reasons they can give denials. The documentation is typically weak. When you are reading a chart a lot of times there are vague categories, or it’s incomplete.

“It’s easy to go through a chart and say ‘OK, we’re going to deny this chart,” Litwin said.

Litwin, who works with home health agencies regarding proper documentation and led a recent lecture on the topic at the 2014 Home Care & Hospice LINK conference, said denials do not always indicate poor quality of care.


As home health care providers struggle to make profit, denials and deficiencies can be a huge determent to providers’ budgets. And, deficiencies can lead to sanctions.

Conducting ongoing clinical record reviews and educating clinicians are key to preparing successful documentation.

Conduct Ongoing Clinical Record Reviews

While many agencies struggle with completing clinical record reviews in a timely manner, ongoing clinical reviews can reduce risk for error, Litwin said.

“You have to have those processes in place to make sure clinicians are documenting correctly,” she said, adding that a quality improvement program provides an extra safety guard.

A good quality improvement program allows providers to see where they’re weak, and assist with troubleshooting and planning.

“Maybe one is your home health aides is not folloiwng the aide care plan, so that would be a deficiency,” she said. “From that [information] you make an action plan, which typically involves education and chart reviews.”

Educate Health Care Partners  

Education to the clinician is key because often the clinician doesn’t know what, how or why they need to document, she said, noting that it’s up to operators to make sure clinicians understand how to properly document.

“A lot of times agencies give up, I’ll hear directors say, ‘It’s like hitting my head against a brick wall,” she said.

While many agencies struggle with face-to-face documentation, especially because of the many doctors home health agencies work with, reviewing documentation right away can help providers catch errors before a denial is issued.

Educating all staff on documentation methods is also helpful, she said.

“Choose clinicians of every discipline that work for you to get involved,” she said. “If they’re involved, they’re learning.”

Written by Cassandra Dowell