Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

LIMITED COMPLIANCE WITH 

MEDICARE’S HOME HEALTH 

FACE-TO-FACE 

DOCUMENTATION 

REQUIREMENTS 

Daniel R. Levinson 

Inspector General 

April 2014 

OEI-01-12-00390 
 

 

 

EXECUTIVE SUMMARY: Limited Compliance With Medicare’s Home Health 

Face-to-Face Requirement 

OEI-01-12-00390 

WHY WE DID THIS STUDY 

The Patient Protection and Affordable Care Act (ACA) requires that physicians (or 

certain practitioners working with them) who certify beneficiaries as eligible for 

Medicare home health services document—as a condition of payment for home health 

services—that face-to-face encounters with those beneficiaries occurred. This study 

(1) determined the extent to which physicians who certified home health care 

documented the face-to-face encounters, (2) described the nature of face-to-face 

documentation, and (3) assessed the Centers for Medicare & Medicaid Services’ (CMS) 

oversight of the face-to-face requirement. 

HOW WE DID THIS STUDY 

We reviewed 644 face-to-face encounter documents to analyze the extent to which the 

documents confirmed encounters and contained the required elements. We interviewed 

the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to 

describe how they ensure that home health agencies met the face-to-face encounter 

requirements. We also reviewed guidance documents and policies from CMS or the 

HH MACs about monitoring the face-to-face requirement. 

WHAT WE FOUND 

For 32 percent of home health claims that required face-to-face encounters, the 

documentation did not meet Medicare requirements, resulting in $2 billion in payments 

that should not have been made. Furthermore, physicians inconsistently completed the 

narrative portion of the face-to-face documentation. Some face-to-face documents 

provide information that, although not required by Medicare, could be useful, such as a 

printed name for the physician and a list of the home health services needed. CMS 

oversight of the face-to-face requirement is minimal. 

WHAT WE RECOMMEND 

We recommend that CMS (1) consider requiring a standardized form to ensure that 

physicians include all elements required for the face-to-face documentation, 

(2) develop a specific strategy to communicate directly with physicians about the face-toface requirement, and (3) develop other oversight mechanisms for the face-to-face 

requirement. CMS concurred with all three of these recommendations. 
TABLE OF CONTENTS 

Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................8 

For 32 percent of home health claims that required face-to-face 

encounters, the documentation did not meet Medicare requirements, 

resulting in $2 billion in payments that should not have been made .....8 

Physicians inconsistently completed the narrative content of the 

face-to-face documentation ....................................................................9 

Some face-to-face documents contain elements that, although not 

required by Medicare, provide information that could be useful .........13 

CMS oversight of the face-to-face requirement is minimal.................14 

Conclusion and Recommendations ............................................................15 

Agency Comments and Office of Inspector General Response ...........17 

Appendixes ................................................................................................18 

A: Samples of Face-to-Face Documents .............................................18 

B: Confidence Intervals ......................................................................24 

C: Agency Comments .........................................................................28 

Acknowledgments......................................................................................31 
 

 

 

OBJECTIVES 

1.	 To determine the extent to which physicians who certified home health 

services documented face-to-face encounters with the beneficiaries 

within the required timeframe. 

2.	 To describe the nature of the face-to-face documentation. 

3.	 To assess the Centers for Medicare & Medicaid Services’ (CMS) 

oversight of the face-to-face requirement. 

BACKGROUND 

The Patient Protection and Affordable Care Act (ACA) provides new tools 

to enhance CMS’s efforts to prevent and detect fraud in its programs. For 

example, the ACA requires certain categories of providers with an 

increased risk for fraud, such as home health agencies (HHAs), to comply 

with enhanced fraud-prevention provisions. Among other steps, the ACA 

requires that physicians (or certain practitioners working with them) who 

certify beneficiaries as eligible for Medicare home health services 

document—as a condition of payment for home health services—that 

face-to-face encounters with those beneficiaries occurred.1 

Medicare Requirements for Home Health Services 

Medicare beneficiaries who are generally confined to their homes may be 

eligible to receive certain medical services at home.2 These home health 

services include part-time or intermittent skilled nursing care, physical 

and/or occupational therapy, speech-language pathology, medical social 

services, and part-time or intermittent home health aide services.3 To 

qualify for home health services, Medicare beneficiaries must (1) be 

homebound; (2) need intermittent skilled nursing care, physical therapy or 

speech therapy, or continuing occupational therapy; (3) be under the care 

of a physician; and (4) be under a plan of care that has been established 

and periodically reviewed by a physician.4 For each 60-day episode of 

care that a beneficiary receives from an HHA, Medicare makes a 

standardized payment. For the HHA to receive that payment, a physician 

1

 P.L. 111-148, § 6407(a), as revised by § 10605 (adding the face-to-face requirement at 

Social Security Act, § 1814(a)(2)(C)). Face-to-face encounters may be performed 

through telehealth visits subject to the requirements in § 1834(m). 

2

 Social Security Act, § 1814(a)(2)(C). 

3

 Social Security Act, § 1861(m); CMS, Medicare Benefits Policy Manual (MBPM), Pub.
 

No. 100-02, ch. 7, § 40.
 4

 42 CFR § 424.22. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 1 
 

 

 

 

 

 

 

 

 

 

 

 

must certify the beneficiary’s initial need for home health services and 

homebound status and must recertify the need at least every 60 days.5 

Homebound Status 

Medicare considers beneficiaries homebound if, because of illness or injury, 

they have conditions that restrict their ability to leave their places of 

residence. Homebound beneficiaries do not have to be bedridden, but 

should be able to leave their residences only with “considerable and taxing 

effort.” Absences from home should be infrequent, for short durations, or for 

health care treatment.6 

Intermittent Skilled Nursing or Therapy Services 

The Social Security Act defines “part-time or intermittent services” as 

“skilled nursing care that is either provided or needed on fewer than 7 days 

each week or less than 8 hours of each day for periods of 21 days or less.”7 

The skilled nursing care must be provided by a registered nurse or licensed 

practical (vocational) nurse under the supervision of a registered nurse.8 

Home health aide services may include personal care, such as bathing and 

dressing; feeding; and simple dressing changes that do not require the skills 

of a licensed nurse.9 Therapy services must be performed by a qualified 

therapist or therapy assistant under the supervision of a qualified therapist.10 

Requirement To Be Under the Care of a Physician 

Medicare requires that to be eligible for home health services, 

beneficiaries be under the care of a doctor of medicine, osteopathy, or 

podiatric medicine.11 As of April 1, 2011, CMS began requiring full 

compliance with the requirement that the certifying physician or clinician 

have a face-to-face encounter with the beneficiary as a condition of 

payment for home health care.12 

Established Plan of Care 

Medicare pays for home health services only if they are provided under a 

plan of care that a physician establishes and periodically reviews.13 The 

physician must review, sign, and date the plan at least once every 60 days.14 

5

 42 CFR § 424.22. 6 MBPM, ch. 7, § 30.1.1. 7

 Social Security Act § 1861(m).
 8 MBPM, ch. 7, § 40.1.1.
 9 MBPM, ch. 7, § 50.2. 10 MBPM, ch. 7, §§ 40.2–40.2.4.3.
 11 42 CFR § 424.22(a)(iv).
 12 ACA, § 6407(a), as revised by § 10605; CMS notice accessed at http://www.cms.gov
 

on November 14, 2013.
 13 42 CFR § 424.22(a)(iii). 

14 MBPM, ch. 7, § 30.2.6.
 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 2 
 

 

 

 

 

 

 

If a beneficiary does not receive at least one covered skilled nursing visit, 

physical therapy visit, speech-language pathology service visit, or 

occupational therapy visit within the 60-day episode, CMS considers the 

plan to be terminated.15 

Face-to-Face Requirement 

For the initial home health episode of care only, the certifying physician 

must document a face-to-face encounter with the patient.16 The HHA must 

obtain documentation that the face-to-face encounter with the patient 

occurred and that the encounter was related to the primary reason the 

beneficiary needs home health care. If the certifying physician does not 

complete the documentation correctly, CMS can deny the HHA payment 

because the face-to-face requirement is a Medicare condition of payment.17 

CMS holds the HHA financially accountable for ensuring that the 

documentation from the physician meets the applicable criteria. 

CMS allows physicians to use a standard form to document the visit. 

However, CMS does not permit a form that the HHA completes and the 

physician merely signs; the physician must actually complete the 

documentation. The documentation must include the following elements 

to meet the condition of payment.18 

1.	 The certifying physician must complete and sign the face-to-face 

documentation, regardless of who performs the face-to-face 

encounter. Federal law mandates as a condition of payment that 

the certifying physician, the physician who cared for the patient in 

an acute-care or post-acute-care facility, or a permitted 

nonphysician practitioner have a face-to-face encounter with the 

patient whom the physician is certifying for home health services. 

CMS has clarified that a patient’s physician for acute care or post15 MBPM, ch. 7, § 30.2.9. 16 Social Security Act, § 1814(a)(2)(C); see also 42 CFR § 424.22(a)(1)(v) (2012) (prior 

to the amendment at 77 Fed. Reg. 67068 (Nov. 8, 2012) (effective Jan.1, 2013)). 

17 The existence of an evaluation and management (E&M) claim does not fulfill the 

face-to-face requirement. E&M claims include visits and consultations performed by 

physicians and nonphysician practitioners. In most situations, if the provider billed 

Medicare for a face-to-face visit with the home health beneficiary, he or she would use an 

E&M code on the claim. 

18 Social Security Act, § 1814(a)(2)(C). See also 42 CFR § 424.22(a)(1)(v) (2012) (prior 

to the amendment at 77 Fed. Reg. 67068 (Nov. 8, 2012) (effective Jan. 1, 2013)); MBPM, 

ch. 7, § 30.5.1.1; and CMS, MLN Matters Article #SE1219, A Physician’s Guide to 

Medicare’s Home Health Certification, including the Face-to-Face Encounter, release 

date May 7, 2012. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 3 
 

 

 

acute care can conduct that encounter as long as he or she informs 

the certifying physician of that encounter.19 

2.	 The certifying physician must title, date, and sign the document.20 

3.	 The face-to-face documentation must be titled as such. CMS does 

not require physicians to use a specific form to document the 

face-to-face encounter; as long as the face-to-face encounter 

documentation contains all content requirements and is properly 

titled, the certifying physician can use a discharge summary, a 

clinic note, or an original form to satisfy the requirement. 

4.	 The date of the encounter must be on the document. 

5.	 The face-to-face encounter must occur within 90 days prior to the 

start of care or within 30 days after the start of care. 

6.	 As required by Medicare, this documentation must include a brief 

narrative that describes (1) why the patient is homebound and 

(2) why the skilled service(s) is necessary to treat the patient’s 

illness or injury. This narrative can address the homebound status 

and reason for skilled service(s) in two separate sections or 

combine them in one section. 

Related Office of Inspector General Work 

In 2012, the Office of Inspector General (OIG) found through a medical 

record review that 98 percent of beneficiaries met Medicare coverage 

requirements for home health services.21 However, OIG also found that 

HHAs submitted 22 percent of claims in error because services were not 

medically necessary or claims were coded inaccurately, resulting in $432 

million in improper Medicare payments. OIG concluded that given the 

general concern about risks to the Medicare program in the home health 

area, further investigations beyond the medical record review are needed 

to determine whether beneficiaries are eligible, services are furnished, and 

Medicare requirements for payment are met. 

19 76 Fed. Reg. 68526, 68593, and 68606 (Nov. 4, 2011). After our review period, CMS 

further revised 42 CFR § 424.22(a)(1)(v) to allow an acute-care or post-acute-care NPP 

to perform the face-to-face encounter in collaboration with or under the supervision of 

the acute or post-acute physician and to allow that physician to inform the certifying 

physician. 77 Fed. Reg. 67068, 67106, and 67163 (Nov. 8, 2012) (effective Jan. 1, 

2013). 

20 After our review period, CMS revised 42 CFR § 424.24(a)(1)(v)(F), effective 

January 1, 2013, so that it no longer provides that only the certifying physician can title 

and date the certification. 77 Fed. Reg. 67068, 67163–64 (Nov. 8, 2012). 

21 OIG, Documentation of Coverage Requirements for Medicare Home Health Claims, 

OEI-01-08-00390, March 2012. 

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In 2012, OIG found that HHAs did not meet all Federal reporting 

requirements for Outcome and Assessment Information Set (OASIS) data, 

which are the basis for home health payments, quality assessments, and 

information for consumers.22 In 2009, HHAs did not submit required 

OASIS data for 392,180 claims (6 percent), which represented over 

$1 billion in Medicare payments. OIG recommended that CMS identify 

all HHAs that failed to submit OASIS data and that the agency apply a 

2-percent payment reduction to them. 

In 2009, OIG found aberrant billing patterns in home health outlier 

payments in 24 counties nationwide.23 One county in Florida, 

Miami-Dade, accounted for more home health outlier payments in 2008 

than the rest of the country combined. 

METHODOLOGY 

SCOPE 

This study determined the extent to which certifying physicians 

documented face-to-face encounters with beneficiaries. This study is 

national in scope. It is based on Part A claims from January 1, 2011, 

through December 31, 2012. 

Claims Analysis. We obtained all home health Part A claims (7,835,502) 

from January 1, 2011, until March 31, 2012, to determine the number of 

initial home health episodes because only these episodes require faceto-face encounters. We determined that 4,226,413 of those claims 

(54 percent) required face-to-face encounters with the physicians who 

certified home health services. We then looked at all claims dated on or 

after April 1, 2011 (2,471,332), which was when CMS started enforcing 

the requirement. 

For those beneficiaries in the first episode of home health care, we 

obtained all Part B claims with dates of service from 90 days prior to or 

30 days after the start of home health care. We used the physician’s 

National Provider Identifier (NPI) number from the Part A home health 

claim and linked it with any Part B claims coded for E&M that had the 

same NPI number. We found that 68 percent of claims (1,679,050) had 

matching Part B E&M claims with the ordering physicians and 32 percent 

(792,282) did not. 

22 OIG, Limited Oversight of Home Health Agency OASIS Data, OEI-01-10-00460, 

February 2012. 

23 OIG, Aberrant Medicare Home Health Outlier Payment Patterns in Miami-Dade
 

County and Other Geographic Areas in 2008, OEI-04-08-00570, December 2009. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 5 
 

Face-to-Face Encounter Documentation. We selected a stratified random 

sample of 680 home health claims and requested from the HHAs the 

documentation of the corresponding face-to-face encounters. To 

determine whether home health claims with matching E&M claims were 

more likely or less likely to meet the Medicare face-to-face requirement, 

we stratified the sample on the basis of whether the Part A home health 

claims had corresponding E&M claims. 

The first stratum included 340 claims that lacked corresponding E&M 

claims. We received 313 face-to-face documents, a 92-percent response 

rate from this stratum. The second stratum included 340 claims that had 

corresponding E&M claims. We received 331 face-to-face documents, a 

97-percent response rate from this stratum. We had a 95-percent total 

response rate for our data collection of face-to-face documents.24 We 

analyzed the extent to which the documents confirmed encounters. We 

also analyzed the face-to-face document to determine the extent to which 

it met the required elements. We compared the percentages of face-to-face 

documents with E&M visits and those without them. 

We found no relationship between the presence of an E&M claim and the 

likelihood that home health agency submitted the face-to-face 

documentation. Thus, we present data in the aggregate. All results are 

weighted to the proportion of the stratum in the population. 

Interviews and Document Review 

We conducted structured interviews with the four Home Health and 

Hospice Medicare Administrative Contractors (HH MACs) regarding how 

they ensure that HHAs meet the face-to-face requirements. We reviewed 

guidance documents or policies from CMS and the HH MACs about 

monitoring the face-to-face requirement. 

Limitations 

This study did not assess the necessity of home health services, and we did 

not make clinical determinations about the appropriateness of the narrative 

portion of the face-to-face document. We limited our analysis to 

describing this narrative text and the absence of required information. We 

also did not independently verify that the information on the face-to-face 

documents was accurate or that the face-to-face encounters were related to 

the primary reasons that the beneficiaries needed home care. 

24 We will refer all HHAs that did not provide copies of the face-to-face documents to 

CMS. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 6 
 

 

For a variety of reasons, an E&M claim corresponding to the home health 

beneficiary’s face-to-face visit may not exist. The physician may not have 

submitted a claim for the service, or the face-to-face encounter may have 

occurred outside of the physician’s office. For example, if the encounter 

occurred in the hospital, the certifying physician may use the hospital 

physician’s documentation of that encounter. In addition, the presence of 

an E&M claim alone does not fulfill the face-to-face requirement; the 

certifying physician must also complete the documentation confirming 

that visit. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 7 
 

FINDINGS 

For 32 percent of home health claims that required 

face-to-face encounters, the documentation did not 

meet Medicare requirements, resulting in $2 billion in 

payments that should not have been made 

Medicare requires as a condition for payment for home health services that 

physicians who certify home health eligibility provide appropriate 

supporting documentation of face-to-face encounters for the initial 

episodes of care. The face-to-face encounter alone does not satisfy the 

requirement; the certifying physician must also complete documentation 

that is clearly titled, signed, and dated. Our review of claims for initial 

episodes of home health care showed that 32 percent either had no 

face-to-face documents or had face-to-face documents that lacked at least 

one of the required elements (see Table 1). We found no difference 

between the home health claims that had corresponding E&M claims and 

the home health claims that did not in the percentage of claims that did not 

meet Medicare requirements. 

Face-to-face documentation was missing in 10 percent of 

claims 

The 10 percent of claims without face-to-face documents totaled 

$605 million. The HHAs either confirmed when we asked them that they 

did not have those documents, or they sent other documents, such as 

physician’s orders, home health referrals, and inpatient notes, which do 

not meet Medicare’s requirements if not appropriately titled as the 

face-to-face documentation. 

Of the face-to-face documents that were submitted, 25 percent 

were missing one of the required elements 

The most commonly missing element was the signature of the certifying 

physician. Seventeen percent ($941 million) of the face-to-face 

documents were signed by persons other than the certifying physicians. 

Medicare regulations allow attending physicians who cared for the 

patients in a recent acute-care or post-acute-care setting, or nonphysician 

practitioners working with the certifying physicians, to conduct the exams. 

However, the certifying physician must document that the encounter took 

place, regardless of who performed the encounter. For 10 percent of 

documents, we were unable to determine whether the signature was that of 

the certifying physician because the physician’s printed name—which is 

not a required element—was missing. (We did not consider these 

documents to be missing in our calculations.) The remaining elements— 

an encounter date within the required timeframe, an appropriately titled 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 8 
 

 

 

document, the date of the encounter, the date the physician signed the 

document, and the existence of a physician’s signature (from either the 

certifying physician or another physician)—were missing much less often. 

(See Appendix A for examples of face-to-face documents.)25 

Table 1: Home Health Documents That Did Not Meet Medicare 

Requirements 

Medicare Requirement Percentage Missing 

From Document* 

Claim Amount 

(in Millions) 

Face-to-Face Documentation 10% $605.3 

Elements Required for Face-to-Face 

Documentation 

Percentage Missing 

From Document 

Claim Amount 

(in Millions) 

Signature of Certifying Physician 17% $941.1 

Date of Encounter Within the Required Timeframe 4% $310.7 

Appropriate Title 3% $150.2 

Date of Encounter 2% $118.8 

Date When Physician Signed Document 2% $106.7 

Physician Signature** 1% $42.3 

Total Claims Missing the Face-to-Face Document 

or Elements of the Face-to-Face Document*** 32% $2,037.0 

Source: OIG analysis of face-to-face documents, 2013. 

*All percentages significant at the p<.05 level. 

**Physician signature left blank. 

***Does not add because of overlapping errors. 

Physicians inconsistently completed the narrative 

content on the face-to-face documentation 

The face-to-face documentation must include a brief narrative that 

describes that patient’s clinical condition and the way in which the 

patient’s clinical condition supports his/her homebound status and the 

need for skilled services. This can be accomplished in as little as three 

sentences. CMS provided the following example in a guidance document: 

The patient is temporarily homebound secondary to status post 

total knee replacement and currently walker dependent with 

painful ambulation. PT [physical therapy] is needed to restore the 

ability to walk without support. Short-term skilled nursing is 

needed to monitor for signs of decomposition or adverse events 

25 These are examples of face-to-face documents collected during this study. We are not 

expressing an opinion whether these examples meet Federal requirements. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 9 
 

 

 

 

from the new COPD [chronic obstructive pulmonary disease] 

medical regimen. 26 

Physicians can document this information in a variety of ways. Some 

physicians use separate statements for each need for skilled services and 

reason that patient is homebound (see Appendix A-1). Others write one 

combined statement similar to the CMS example (see Appendix A-5). 

CMS gives physicians discretion as to how they document this 

information; however, CMS will consider the face-to-face documentation 

incomplete without this narrative. Because the face-to-face requirement is 

a Medicare condition of payment, CMS will deny the payment for the 

initial and all subsequent episodes of care.27 

Narratives did not always appear to follow CMS guidance for 

describing homebound status and necessity for skilled 

services 

Some face-to-face documentation failed to specify why the patient was 

homebound or to include the reason the skilled service was necessary. In 

those face-to-face documents that had separate statements for each piece 

of the narrative, 12 percent were missing narratives supporting the 

patients’ homebound status and 6 percent were missing narratives 

regarding the need for skilled services.28 

Some of the language in the narratives does not appear to conform to 

guidance about what constitutes appropriate and sufficient documentation. 

CMS and its contractors released guidance that included examples of 

language that would be considered inappropriate if used alone.29, 30 (See 

Table 2 for examples.) We found that, in their descriptions of the 

beneficiaries’ homebound status, 16 percent of documents said that the 

beneficiaries were weak and 14 percent said that the beneficiaries were 

unable to leave home unassisted. (See Table 3 for the reasons most 

commonly cited in the narrative text.) 

26 CMS, Home Health Face-to-Face Question & Answer, February 28, 2013. Accessed
 

at http://www.cms.gov on August 7, 2013. 27 Ibid. 

28 Because we did not render an opinion about the appropriateness of the narratives, we 

did not determine whether these face-to-face documents failed to meet CMS 

requirements. 

29 CMS, Home Health Face-to-Face Question & Answer, February 28, 2013. Accessed 

at http://www.cms.gov on August 7, 2013. 30 CGS, Face-to-Face Documentation for Home Health Certification: Important
 

Information for Certifying Physicians and Nonhysician Practitioners. Accessed at 

http://www.cgsmedicare.com/ohb/pubs/mb_J15/2013/08_2013/index.html on August 7,
 

2013. 

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Table 2: CMS Contractors’ Examples of Text That Is Insufficient To 

Support Home Health Claims 

Text Insufficient To Support 

Homebound Status 

Weak 

Unable to drive 

Unable to leave home 

Dementia or confusion 

Functional decline 

Text Insufficient To Support 

Need for Skilled Services 

Family is asking for help 

Continues to have problems 

List of tasks for nurse to do 

Patient unable to do wound care 

Diabetes 

Source: CGS, 2013 Face-to-Face Documentation for Home Health Certification: Important Information for 

Certifying Physicians and Non-physician Practitioners. 

Table 3: Most Commonly Used Narrative Text Supporting 

Homebound Status 

Characteristic Percentage of Narrative Texts That 

Cited Characteristic 

Taxing effort to leave home 17% 

Weakness/fatigue 16% 

Unable to leave home unassisted 14% 

Unsteady gait/risk of falls 13% 

Decreased mobility 10% 

Shortness of breath/dyspnea 9% 

Poor endurance 7% 

Source: OIG analysis of face-to-face documents, 2013. 

The most commonly used phrase was “taxing effort to leave home.” 

Physicians used this phrase in 17 percent of face-to-face documentation to 

explain their patients’ homebound status. In fact, in about half of those 

documents, the physicians did not list any other reasons. The phrase 

“taxing effort to leave home” is included in CMS’s definition of 

homebound, and, therefore, offers no specific statement about the patient’s 

condition.31 

31 MBPM, ch. 7, § 30.1.1. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 11 
Some face-to-face documents contain elements that, 

although not required by

information that 

 Medicare, provide 

could be useful 

 

I certify that my clinical findings support that this patient is homebound (i.e., absences 

from the home require a taxing effort, are for medical appointments and services, or are 

infrequent and of short duration for other reasons such as religious services, etc.) as 

evidenced by:
 

	 Patient is unable to drive (permanently or temporarily) due to current illness, 

surgery, or debility 

	 Patient is non-weight bearing or requires assistance/assistive device(s) 

	 Patient requires constant supervision for safety reasons (either cognitive or 

functional, or both) 

	 Patient has a mental health diagnosis that prevents their ability to leave home 

	 Other:_____________________________________________________ 

 

 

 

Some of the language in the narratives was similar to the language that 

CMS and its contractors cited as inappropriate. Moreover, the 

combinations of many of these phrases in the same document raised 

questions about whether using multiple phrases that are considered 

inappropriate individually constitutes a narrative that CMS and its 

contractors would find sufficient to justify the need for home health when 

used together. 

HH MACs vary as to whether they accept forms with 

checkboxes in the face-to-face documentation 

HH MACs appear to interpret CMS’s guidance on forms with 

checkboxes—i.e., forms that list several possible conditions or 

characteristics, with a box next to each that the physician can mark with a 

check—differently. CMS allows forms with checkboxes in limited 

situations; however, the option next to each checkbox must contain the 

physician’s assessment specific to that patient. In our interviews, one of 

the four HH MACs offered that it does not accept forms with checkboxes 

unless the physician writes additional information. 32 Another HH MAC 

said that it looks at each form on a case-by-case basis and makes its 

determination, in part, on the basis of whether the form was designed by 

the HHA or the physician. The use of checkboxes in some forms also 

raised questions about the extent to which the narrative content meets 

Medicare requirements. Six percent of face-to-face documents used 

checkboxes on the forms. (See Image 1.) 

Image 1: Checkboxes on Face-to-Face Document 

Source: Example from OIG face-to-face document review, 2013. 

32 CMS does not allow checkboxes created by HHAs. CMS does allow checkboxes 

created by physicians or generated from physicians’ electronic health records. CMS, 

Home Health Face-to-Face Question & Answer, February 28, 2013. Accessed at 

http://www.cms.gov on March 12, 2014. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 12 
 

Some face-to-face documents contain elements that, 

although not required by Medicare, provide 

information that could be useful 

Medicare requirements specify which elements must appear on the 

face-to-face document; however, additional elements could add clarity to 

the document. 

NPI. Seven percent of documents listed the certifying physicians’ NPIs. 

Including this number makes it easier to identify the physician, especially 

when the handwriting is illegible. The printed names of the physicians 

were illegible in 4 percent of the documents. 

Printed Name of Physician. In addition to the required physician 

signature, most documents included the printed (either handwritten or 

typed) names of those physicians. Ten percent of face-to-face documents 

were missing a printed name. Many signatures were illegible, and a 

printed name may be the only way to identify the certifying physician. 

Name of Nonphysician Practitioner. Medicare regulations allow a 

nonphysician practitioner to complete the face-to-face encounter. Five 

percent of documents provided a dedicated space to identify those 

individuals. 

Letterhead of HHA or Hospitals. Slightly over half (58 percent) of the 

documents contained the letterheads of either the HHAs or the hospitals. 

This could indicate that these facilities use standardized forms for the 

physicians to complete. 

List of Home Health Services Needed. Most face-to-face documents had 

checkboxes to indicate a need for nursing (81 percent), physical therapy 

(80 percent), or speech/language pathology (76 percent). Far fewer 

documents included checkboxes for occupational therapy (36 percent), 

home health aide services (21 percent), or a medical social worker 

(20 percent). (See Image 2 for an example.) 

Image 2: List of Home Health Services Needed 

 

 

 

I certify that, based on my findings, the following services are medically 

reasonable and necessary:
 

 Skilled Nursing 

 Physical Therapy 

 Speech Language Pathology 

 Occupational Therapy 

 Medical Social Worker Consult 

 Home Care Aide (for personal care) 

Source: Example from OIG analysis of face-to-face documents, 2013. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 13 
 

 

 

CMS oversight of the face-to-face requirement is 

minimal 

CMS does not have a specific program to oversee compliance with the 

requirement for face-to-face documentation. Instead, it reviews the 

documentation when it conducts a medical record review as part of its 

general effort to deter and detect home health fraud. Because the 

face-to-face encounter is required for the initial episodes only, just a 

fraction of those reviews would include the face-to-face document.33 

In their medical record reviews, the four HH MACs do not verify the 

information on the face-to-face documents. In particular, they do not 

confirm that the physician who signed the document is actually the 

certifying physician. HH MACs cited lack of access to Medicare Part B 

physician claims and limited time and resources as major reasons why 

they do not verify the information. 

Although they do not verify the face-to-face document, the HH MACs do 

offer guidance and training on the requirement. All four HH MACs point 

to training that they offer HHAs about the face-to-face requirement, 

including Web sites, Web seminars, and provider presentations. Two 

HH MACs also reached out to the physician community in an attempt to 

address problems they have seen, such as insufficient narratives and 

failure to sign and date the documents. However, in our interviews with 

HH MACs, they told us that they are limited in their interactions with 

physicians, because activities such as training for those providers are not 

the responsibility of the HH MACs. 

Like the HH MACs, HHAs rely on physicians’ accurately completing the 

face-to-face documents. All four HH MACs reported that HHAs had 

expressed frustration about the burden that the face-to-face document 

imposes. HHAs are held financially accountable for failure to obtain the 

face-to-face documentation but have no authority to compel physicians to 

complete it either timely or accurately. 

33 Reviews of claims for continuing home health care do not require a face-to-face visit. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 14 
 

 

CONCLUSION AND RECOMMENDATIONS 

Home health fraud has been well documented, and efforts to uncover it are 

ongoing. In July 2013, CMS issued a temporary moratorium on new 

home health providers in parts of Florida and Illinois to fight fraud in 

Medicare.34 As another fraud prevention strategy, Medicare also requires 

as a condition of payment that a beneficiary have a face-to-face encounter 

with the physician, or certain practitioners working with them, who 

initially certified that patient for Medicare home health services. 

However, our findings show that 32 percent of claims for home health 

services that required face-to-face encounters did not meet Medicare 

requirements, resulting in $2 billion of payments that should not have been 

made. 

We also found that CMS lacks an adequate oversight mechanism to ensure 

that this face-to-face requirement is met. Ensuring that an oversight 

mechanism is in place will also prove instructive for CMS as it 

implements a similar face-to-face requirement for durable medical 

equipment in the future. 

We recognize that the very design of the Medicare home health payment 

system makes oversight of the face-to-face requirement difficult. Four 

HH MACs process Part A and B home health claims. However, the actual 

physician encounter that would establish the face-to-face eligibility is 

covered under Part B, which may be administered by a separate MAC. As 

a result, matching claims associated with one beneficiary under the two 

separate systems is not readily achievable. In addition, HHAs, which are 

required to obtain the face-to-face documents in order to receive payment, 

have no authority to compel physicians to complete and sign the 

documents. 

As a way to help bridge this gap and to further the intent of the 

face-to-face requirement, we recommend that CMS: 

Consider requiring a standardized form to ensure that 

physicians include all elements required for the face-to-face 

documentation 

To enhance oversight and to clarify completion of the required elements, 

CMS should consider requiring the use of a standardized form to serve as 

the face-to-face documentation. Because over half of the face-to-face 

documents are completed using standardized forms from hospitals or 

HHAs, this should not be a significant adjustment for most physicians. 

34 78 Fed. Reg. 46339 (July 29, 2013). 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 15 
 

Develop a specific strategy to communicate directly with 

physicians about the face-to-face requirement 

CMS needs to provide additional formal training and outreach about the 

importance of completing the face-to-face document. Because HH MACs’ 

responsibility to conduct provider outreach does not extend to physicians, 

HH MACs are not directly training physicians. It is therefore incumbent 

upon CMS to identify ways to educate the physician community about the 

requirements. 

Develop other oversight mechanisms for the face-to-face 

requirement 

Relying on medical record reviews to ensure that HHAs are meeting the 

face-to-face requirement is clearly not sufficient. CMS could work with 

the various payment contractors to develop other review procedures to 

ensure compliance. This charge has heightened importance given CMS’s 

plans to implement the face-to-face requirement for durable medical 

equipment. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 16 
 

 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

CMS concurred with all three of the recommendations in this report. To 

address our first recommendation, CMS stated that it will consider 

whether requiring a standardized form will help resolve issues identified in 

our report. We recognize that using a standardized form may eliminate 

some flexibility for physicians; however, CMS must ensure that all 

required elements are present on the face-to-face document. 

To address our second recommendation, that CMS develop a specific 

strategy to communicate directly with physicians about the face-to-face 

requirement, CMS plans to issue additional educational materials to 

physicians. 

To address our final recommendation, CMS stated that it is implementing 

an oversight plan through the Supplemental Medical Review Contractor 

(SMRC). CMS will have the SMRC conduct document-only reviews for 

every HHA in the country to validate a sample of the face-to-face 

encounters. 

Lastly, we withdrew a recommendation from our draft reports that CMS 

require physicians to include their NPIs on the face-to-face document. As 

of July 1, 2014, CMS will require that HHAs report the NPI of the 

certifying physician and the physician who signed the plan of care, if 

different from the certifying physician.35 We believe that this new 

requirement satisfies our original recommendation without imposing any 

additional burden. 

For a full text of CMS’s comments, see Appendix C. 

35 CMS Manual System, Pub. No. 100-04, Medicare Claims Processing, Transmittal 

2789, Change Request 8441, Sept. 20, 2013. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 17 
 

 

APPENDIX A-1: SAMPLES OF FACE-TO-FACE DOCUMENTS 

 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 18
 
 

 

APPENDIX A-2 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 19
 
 

APPENDIX A-3 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 20
 
 

APPENDIX A-4 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 21
 
 

 

APPENDIX A-5 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 22
 
 

 

APPENDIX A-6 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 23
 
 

 

 

 

APPENDIX B – CONFIDENCE INTERVALS 

Characteristic Sample Size Percentage 

(95-Percent Confidence 

Interval) 

Claims that did not meet the face-to-face 

requirement 644 

32.2% 

(28.4%–36.0%) 

Claims without face-to-face 

documentation 644 

9.7% 

(7.2%–12.1%) 

Face-to-face documents that were 

missing at least one required element 583 

25.0% 

(21.2%–28.6%) 

Face-to-face documents without 

appropriate titles 583 

2.8% 

(1.5%–4.2%) 

Face-to-face documents that were not 

dated by physicians 583 

2.0% 

(0.2%–1.8%) 

Face-to-face documents missing dates of 

face-to-face encounters 583 

1.6% 

(0.5%–2.7%) 

Face-to-face documents not signed by 

physicians 583 

1.0% 

(0.2%–1.8%) 

Face-to-face documents not signed by 

certifying physicians 583 

17.0% 

(13.8%–20.2%) 

Face-to-face documents not completed 

within the required timeframe 583 

4.2% 

(2.5%–6.0%) 

Face-to-face documents not dated by 

physicians 583 

2.0% 

(.9%–3.2%) 

Face -to-face documents lacking printed 

names or contraining llegible printed 

names for the signing physicians 

583 

13.7% 

(10.7%–16.7%) 

Face-to-face documents using 

checkboxes 583 

6.1% 

(4.0%–8.1%) 

Source: OIG analysis of face-to-face documents, 2013 Cont’d 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 24 
 

 

 

 

Characteristic Sample Size Percentage 

(95-Percent CI) 

Face-to-face documents for which it was 

not possible to determine whom the 

signatures belonged to 

583 

11.9% 

(9.0%–14.7%) 

Face-to-face documents missing at least 

one required element 583 

21.5% 

(18.0%–25.0%) 

Face-to-face documents missing 

narrative justifying beneficiaries’ 

homebound status 

583 

11.9% 

(9.0%–14.7%) 

Face-to-face documents without narrative 

for beneficiaries’ need for skilled services 583 

5.9% 

(3.9%–7.9%) 

Face-to-face documents with narrative 

citing taxing effort for beneficiaries to 

leave home 

583 

17.3% 

(14.0%–20.6%) 

Face-to-face documents with narrative 

listing beneficiaries’ weakness/fatigue 583 

16.0% 

(12.9%–19.2%) 

Face-to-face documents with narrative 

describing beneficiaries as unable to 

leave home unassisted 

583 

14.2% 

(11.2%–17.3%) 

Face-to-face documents with narrative 

listing beneficiaries’ unsteady gait 583 

13.1% 

(10.2%–16.1%) 

Face-to-face documents with narrative 

listing beneficiaries decreased mobility 583 

9.6% 

(7.1%–12.2%) 

Face-to-face documents with narrative 

listing beneficiaries’ shortness of 

breath/dyspnea 

583 

9.0% 

(6.4%–11.5%) 

Face-to-face documents with narrative 

listing beneficiaries’ poor endurance 583 

6.0% 

(4.6%–8.1%) 

Face-to-face documents listing the 

physicians’ NPIs 583 

6.8% 

(4.6%–9.1%) 

Face-to-face documents with illegible 

printed names for the signing physicians 583 

4.1% 

(2.2%–5.8%) 

Source: OIG analysis of face-to-face documents, 2013 Cont’d 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 25 
 

 

Characteristic 

Sample Size Percentage 

(95-Percent CI) 

Face-to-face documents with a space to 

list a nonphysician practitioner 583 

5.0% 

(3.2%–6.7%) 

Face-to-face documents with letterhead 

of hospitals or HHAs 583 

58.3% 

(54.1%–62.6%) 

Face-to-face documents with a checkbox 

for nursing 583 

81.4% 

(78.0%–84.8%) 

Face-to-face documents with a checkbox 

for physical therapy 583 

79.7% 

(76.3%–83.2%) 

Face-to-face documents with a checkbox 

for speech therapy 583 

76.2% 

(72.5%–79.9%) 

Face-to-face documents with a checkbox 

for occupational therapy 583 

36.1% 

(32.0%–40.3%) 

Face-to-face documents with a checkbox 

for home health aide services 583 

20.9% 

(17.4%–24.4%) 

Face-to-face documents with a checkbox 

for medical social worker 583 

19.8% 

(16.4%–23.2%) 

Source: OIG analysis of face-to-face documents, 2013 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 26 
 

 

Table B1: Claims That Should Not Have Been Paid 

Reason Claim Should Not Have Been 

Paid Sample Size Dollars 

(95-Percent Confidence 

Interval) 

Claim did not meet Medicare 

requirements 644 

$2,027.0 

($1,728.7–$2,325.3) 

Claim did not provide a face-to-face 

document 583 

$605.3 

($479.5–$731.1) 

Face-to-face document was signed by 

someone other than certifying physician 583 

$941.1 

($820.6–$1,061.7) 

Face-to-face document was not 

completed within the required timeframe 583 

$310.7 

($222.1–$399.2) 

Face-to-face document did not have an 

appropriate title 583 

$150.2 

($100.4–$200.0) 

Date of face-to-face encounter was 

missing 583 

$118.8 

($55.6–$182.1) 

Face-to-face document was not signed 

by a physician 583 

$42.3 

($22.0–$62.7) 

Face-to-face document was not dated by 

physician 583 

$106.7 

($60.6–$152.8) 

Source: OIG analysis of face-to-face documents, 2013 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 27 
APPENDIXC 

Agency Comments 

DEPARThfENT OF HEALTH & HUMAN SERVICES Cantors for Modlcaro & Medica•d Services 

~- - --~ ---·--------- ~--------~-~ --~ =~ --~- ---

Atlmlttlstrator 

Washington, DC 20201 

DATE: JAN 3 1 2014 

TO: Daniel R. Levinson 

Inspector General 

FROM: Marilyn Tavenner 

Administrator 

SUBJECT: Otlice of Inspector General (O!G) Draft Report: ''Limited Compliance with 

Medicare's Home Health Face-To-Face Documentation Requirements" 

(OEI-0 1-12-00390) 

Thank you for the opportunity to review and comment on the subject report. Congress mandated 

face-to-face encounters in order to increase physician involvement with Medicare home health 

(1111) beneficiaries :md, as part of the certification for Medicare HH services, to assure a patient's 

eligibility for the Medicare HI! benefit. 

The OIG reports that 32 percent of HH claims that required a face-to-lace encounter did not meet 

Medicare requirements, either missing the face-to-face documentation altogether or lacking in at 

lt::ast one of the required elements. To address those inadequacies, OIG recommends that CMS 

consider requiring a st:mdardized form for documenting the physician encounter, conducting 

physician specific outreach, and evaluating alternative oversight mechanisms. The OIG's 

analysis and recommendations are focused on strengthening the HI-I face-to-face requirements to 

ensure that valid and meaningful physician involvement is occurring, and that the health care 

needs of Medicare HH beneficiaries are met. CMS appreciates OIG's analysis and 

recommendations, and will continue lo work with health care providers. specifically physicians, 

non-physician pmctit.ioners, and home health agencies (!!HAs), to help them comply with the 

HH face-to-face requirements 

The OIG recommendations and ClviS responses to those recommendations are discussed below. 

OIG Recommendation 

The OTG recommends that CMS consider requiring a standardized form to ensure that physicians 

document all clements required for the face-to-face documentation. 

Limited Compliance With Medicare's Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 28 
 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 29 
 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 30 
 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Joyce Greenleaf, Regional 

Inspector General for Evaluation and Inspections in the Boston regional 

office; Russell Hereford, Deputy Regional Inspector General; and 

Kenneth Price, Deputy Regional Inspector General. 

Danielle Fletcher served as the team leader for this study. Other Office of 

Evaluation and Inspections staff from the Boston regional office who 

conducted the study include Amy Glynn. Central office staff who 

provided support include Clarence Arnold, Heather Barton, 

Mandy Brooks, and Christine Moritz. 

Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements (OEI-01-12-00390) 31 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.