Home Health & Hospice Week

Documentation process and content problems plague HHAs trying to comply.

New face-to-face requirements took effect Jan. 1, but chances are your referral sources only know about them if you educated them.

In a December National Provider Call on the new F2F requirements, the Centers for Medicare & Medicaid Services did not acknowledge the additional burden that will come with home health agencies asking physicians for their clinical records to support HHA claims.

“We understand that some challenges arise when the physician’s documentation is relied upon to make coverage determinations of home health and other services and supplies,” said CMS’s Jill Nicolaisen in the call. “We plan on conducting outreach activities to physicians to educate them on the new home health certification requirements.”

But “to date, CMS has not issued any guidance or initiated any education on the new requirement that physicians have sufficient documentation in their own files to support the certification of homebound status and skilled care need,” protests the National Association for Home Care & Hospice.

“The CMS folks remain out of touch with the kind of documentation that physicians typically complete and the level of understanding they have of the home health benefit and how it works,” says Chicago-based regulatory consultant Rebecca Fried-man Zuber. “In fact, CMS seems willfully out of touch.”

“CMS does not understand how difficult the sharing of documentation can be,” Zuber continues. “Or the fact that the historic flow of documents has been from the home health agency to the physician — not the other way around.”

“I do not believe CMS has the faintest idea about how difficult it is for agencies and physicians to share records,” agrees Judy Adams with Adams Home Care Consulting in Asheville, N.C. CMS also seems to lack “a very clear understanding of the way physicians document.”

Result: “Confusion still reigns for HHAs regarding how to comply with the F2F requirements,” Adams tells Eli.

Documentation Content Requirements Are Unrealistic

The process isn’t the only problem with the new rule. “NAHC is concerned about the depth of documentation that CMS is expecting from physicians” under the new requirement, it says. “NAHC is also concerned about the standard that documentation from the HHA alone is insufficient to support the physician certification and that it can be used only if it corroborates other documentation not prepared by the HHA.”

“Sharing documentation is in some ways the least of it,” Zuber tells Eli. “You have to have documentation that meets CMS’ unrealistic standard to share.”

In the call, Nicolaisen noted that “we intend to provide additional guidance in our manuals about the corroborating documentation we would expect to see in the [physician] record in order to support pa-tient eligibility.” But again, CMS has not yet issued those manual updates.

Frustration Level Rises

“Providers are very confused and frustrated” about the new requirements, Zuber relates. “They feel that once again CMS has issued an edict that will be difficult to meet and that requires them to rely on the actions of others outside their control to get paid.” 

Strained relationships: “Compliance-oriented home health providers are once again squarely in the face of their physician partners with another set of seemingly impossible expectations with little guidance from CMS on what will actually qualify to meet them,” Zuber criticizes.

NAHC urges agencies to channel their frustration into an appeal for a delay on this requirement. In December, NAHC and other parties requested a phase-in of the requirements, and in the call CMS’s Randy Throndset noted that “senior management” was reviewing the requests from NAHC, the Visiting Nurse Associations of America, and others and “formulating a response.” He continued, “officials are looking at that and will be communicating on that aspect in the near future.” But at press time, CMS had not issued a public response to delay requests.

CMS also has yet to respond to a December congressional report asking the agency to justify its F2F requirement. The House and Senate report, which accompanied the 2015 omnibus appropriations bill passed last month, says that CMS should “quantify and explain how the policy directing physicians to conduct face-to-face certifications for home health care has prevented fraud, increased access to health care, and impacted costs to the Medicare and Medicaid programs,” NAHC notes. Additionally, the report directs CMS to include ways to simplify provider documentation for F2F as part of its 2016 budget request.

NAHC is  urging agencies to ask CMS and their elected officials again for a phased-in approach to enforcement of this requirement. CMS should put off enforcement until it has issued comprehensive guidance on compliance and education of physicians and home health agencies, NAHC contends.

“Most HHAs are still waiting for better direction from CMS on this new process which continues to present a hardship for agencies,” Adams observes.