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Why isn't Mary receiving the home health care her physician ordered?
Last Modified: 4/4/2024
Location: FL, PR, USVI
Business: Part A, Part B
Mary is a Medicare beneficiary seeking home health services following an inpatient stay. Unfortunately, Mary's physicians are not complying with Medicare requirements; therefore, Medicare has denied her claims. The Home Health Agency (HHA) is unwilling to continue to provide services without Medicare reimbursement.
Mary was in the hospital with a hospitalist responsible for her care. The hospitalist worked diligently to diagnose and treat her illness or injury. Mary's condition improved and she is now able to go home. The hospitalist determines Mary will be confined to her home and will need intermittent skilled nursing care and physical therapy. The hospitalist and staff made arrangements with the local HHA to treat Mary and provide her the skilled care and physical therapy she needs. The hospitalist transfers Mary's care to her primary care physician.
Unfortunately, neither the hospitalist nor the primary care physician replies to the request for documentation. Medicare will deny the home health claim or recoup any payment made when the HHA is not able to provide the necessary documentation. The HHA is no longer able to care for Mary since there will be no Medicare payment.
The primary care physician believes that Mary is receiving skilled nursing services and physical therapy to assist her in recovering from her illness. However, Mary is not receiving care and that neglect will be apparent at the next in-person visit.
To ensure Mary can access her Medicare benefits and to assist the HHA in providing the services that you and the hospitalist have ordered for Mary, please verify Mary's medical record contains the necessary information and provide this to the HHA when requested.
The HHA may determine not to take referrals from the individual physicians in the future, if they continue to have trouble in gathering the documentation to support Medicare payment for the services.
Actions to take:
• Verify Mary's medical record both in the inpatient facility and the physician's office contains the necessary information.
• Validate Mary is unable to leave her home without great difficulty and describe her challenges and any accommodation needed.
• Describe Mary's specific needs, the treatment and goals for Mary and which professional will go into home.
• Verify Mary has had a face-to-face visit within the 90-day period prior to the start of home health or within 30 days after the start of the home health and is related to the reason for home health.
• Share the medical record with the HHA when requested.
To assist the HHA in providing and receiving appropriate reimbursement for Mary (and other patients), please submit the appropriate documentation when requested to do so. This will ensure the HHA can receive appropriate Medicare payment and your patient's care will not need interrupted or discontinued.
This document was developed through the A/B Medicare Administrative Contractor Home Health and Hospice Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.
Note: First Coast Service Options (First Coast), as the jurisdiction N Part A and B Medicare administrative contractor (JN A/B MAC), does not process claims for home health and hospice services. Florida home health and hospice claims are processed by
Palmetto GBA as the regional home health intermediary (RHHI).
National Government Services (NGS) is the RHHI responsible for Puerto Rico and the U.S. Virgin Islands.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.