If you attended Tuesday’s Phase 6 Medicare Home Health/Third Party Liability Training put on by the Center for Medicare Advocacy, you know that time ran out before CMA could explain what DSS’s position would be for recouping for lack of face-to-face (F2F) documentation for Phase 4 forward of the TPL project. I posed the question to Judy Stein, Executive Director of CMA, after the training and followed up in writing. Here’s my question and her response:
Question by Pamela Meliso: As promised, here’s my request for clarification on potential provider liability based on lack of valid F2F documentation. As you know, 42 CFR §489.21(b)(1) states that a provider cannot bill a beneficiary for services that would have been paid for if the required certification documentation had been submitted with the payment request. In other words, coverage must be established before the State could recoup based on lack of valid F2F. Will you please confirm that this is your (and the State’s) understanding as well?
Answer from Judy Stein: And yes, your understanding is correct. Since F2F is a payment issue, first Medicare coverage has to be granted; only then should a decision be made regarding whether or not Medicare payment will issue. If coverage is granted, but Medicare payment can’t be made because the provider failed to meet a payment requirement – in this case F2F – only then will DSS recoup the Medicaid payment.
There was a time when Medicare contractors were jumping right to F2F and holding providers liable if the F2F wasn’t in the file. But that is incorrect. We contacted the contractors and told them that the contractor needed to do a thorough medical review and F2F is the last thing to look at and only if coverage is granted. I think that is now the case.
We need to make sure that the State and DSS adhere to this narrower standard for recoupment based on lack of F2F documentation. Please feel free to contact me at email@example.com with any questions or if I can provide any assistance to you in fighting unwarranted recoupment of Medicaid payments by the State.