Denials begin for PoC without physician approval

The National Association for Home Care & Hospice (NAHC) recently learned that home health agencies have begun to receive Medicare denials because they provide services and treatments in accord with a plan of care developed after assessing the patient, without obtaining prior approval from the physician for the treatments and services in the plan. In these cases, nurses and therapists conduct patient assessments, initiate care in accord with the referral and create a written plan of care based on assessed needs. They then mail or fax this plan of care to the physician without first receiving approval from the physician for visits and treatments included in the plan of care.

As a result, services that were provided after the initial visit and up to the date of the physician’s signature on the plan of care are denied for lack of physician orders.

The Conditions of Participation (CoP) at 42 CFR 484.18(a) requires that the plan of care be developed in consultation with the agency staff, and that the physician be consulted to approve additions or modifications to the original plan. Further, the CoP require that therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration.

The Medicare coverage rules at 42 CFR § 409.43 specify that the plan of care must contain those items listed in the CoP at 42CFR §484.18(a) and that physician’s orders for services in the plan of care must specify the medical treatments to be furnished as well as the type of home health disciplines that will furnish the ordered services and at what frequency the services will be furnished.

See the Medicare Benefit Policy Manual (cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c07.pdf) for more specific information, including guidance on oral orders.

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