Our audit reviews continue to reveal the same key issues: eligibility, certification, and documentation. Medicare home health coverage isn’t just about providing care—it’s about clearly demonstrating the medical necessity through accurate and timely records. Home Health Eligibility: All Criteria Must Be MetTo qualify for Medicare home health services, the patient must: Plan of Care (POC)…
Our audit reviews continue to reveal the same key issues: eligibility, certification, and documentation. Medicare home health coverage isn’t just about providing care—it’s about clearly demonstrating the medical necessity through accurate and timely records.
Home Health Eligibility: All Criteria Must Be Met
To qualify for Medicare home health services, the patient must:
- Have Medicare Part A and/or B
- Be homebound with clear documentation
- Require intermittent skilled care (SN, PT, SLP, or OT)
- Be under the care of a physician or allowed practitioner
- Receive care under a certified Plan of Care (POC)
- Have had a face-to-face encounter with a physician or NPP within the required timeframe
Plan of Care (POC) & Certification: Where We See Issues
Common errors include:
- POCs not signed and dated by the certifying physician prior to billing
- Incomplete plans—missing frequencies, medications, diagnoses, or functional limitations
- Certifications that don’t align with the POC or are missing altogether
- Recertifications that are delayed or signed by someone other than the certifying physician
Reminder: The same physician who establishes the POC must also certify and recertify every 60 days.
Face-to-Face Encounter: A Persistent Denial Risk
To meet requirements, the face-to-face:
- Must occur no more than 90 days prior to or 30 days after the start of care
- Must be directly related to the reason for home health
- Must be performed and documented by an allowed provider type
- Must include the actual clinical note, not just a summary
If the face-to-face documentation isn’t complete and timely, payment for the episode can be denied.
Need Help Navigating ADRs? We’ve Got You Covered.
At MAC Legacy, we don’t just point out problems—we help fix them. Our compliance experts support agencies with:
- Strong, defensible ADR responses
- Thorough record reviews
- Staff education and policy refinement
We’re here to help you protect your revenue and your reputation—every step of the way.
