Home Health & Hospice Week

Continue to collect the narrative until CMS implements the change, experts warn.

After years of suffering under the onerous physician face-to-face encounter requirement, the end is in sight.

In the 2015 home health prospective payment system proposed rule, the Centers for Medi-care & Medicaid Services announces plans to end the controversial physician narrative portion of the F2F requirement. “In an effort to simplify the face-to-face encounter regulations, reduce burden for HHAs and physicians, and to mitigate instances where physicians and HHAs unintentionally fail to comply with certification requirements, we propose that … (t)he narrative requirement … would be eliminated,” CMS says in the proposed rule.

However: “The certifying physician would still be required to certify that a face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician … and to document the date of the encounter as part of the certification of eligibility,” CMS says.

Exception: “For instances where the physician is ordering skilled nursing visits for management and evaluation of the patient’s care plan, the physician will still be required to include a brief narrative that describes the clinical justification of this need as part of the certification/recertification of eligibility,” CMS notes. “This requirement was implemented in the CY 2010 HH PPS final rule … and is not changing.”

“This change is huge and is an acknowledgement by CMS that F2F has become a huge problem,” says attorney Robert Markette Jr. with Hall Render in Indianapolis.

“We are delighted that CMS has heard and acted upon our recommendations,” says Val Hala-mandaris of the National Association for Home Care & Hospice, which filed a lawsuit over the matter last month.

“The elimination of the physician narrative ... is a welcome proposal,” says the Visiting Nurse Associations of America. “We are hopeful these proposed changes will satisfy providers and payers alike.”

CMS lists a number of reasons for the change. For one, the 2013 Comprehensive Error Rate Testing (CERT) report found a 17 percent error rate for home health agency claims, largely due to F2F physician narrative problems. Also, the home care industry has expressed “concerns” and “frustration” about the requirement, including that it is redundant and goes beyond Congressional intent.

“They may also have realized that they were pretty far out on a limb with the regulation they promulgated to implement face to face,” Markette says of CMS.

CMS does not cite the recent F2F lawsuit filed by NAHC as a reason for its decision, but experts agree that likely was a factor in the change.

This change seems relatively quick after the lawsuit’s filing. But “I would not call CMS’ move ‘quick,’” says Washington, D.C.-based attorney Eliz-abeth Hogue. “HHA management and staff have suffered a lot of heartburn over this issue.”

“We have had F2F since 2011,” agrees Tom Boyd with Simione Heatlhcare Consultants in Rohnert Park, Calif. “Medicare spending on HHAs has decreased from $19.4 billion to $18 billion (or less) and [Administrative Law Judges] now have a 28-month backlog in part due to F2F.”

“CMS was facing a lot of heat on this,” notes financial consultant Mark Sharp with BKD in Springfield, Mo. “They needed to do something to try and alleviate the onerous burden of the initial F2F requirements.”

Narrative Not Eliminated Yet

Don’t count on your F2F relief right away. “This is the proposed rule and does not go into effect for a while,” Markette points out. In fact, it “may go into effect in a completely different manner,” he cautions. And reviewers looking at claims before the effective date would still be able to deny claims based on the requirement in effect at the time.

A typical effective date for items in the PPS rule is Jan. 1, but home health agencies hope they don’t have to wait that long for relief from the narrative requirement. “It would be extremely helpful if this was combined with either a retroactive effective date or a directive to auditors to not audit face to face narratives for content,” Markette tells Eli. “This would have the practical effect of implementing the proposed change immediately.”

“I want CMS to say that they won’t recoup monies related to insufficient narratives on the F2F,” Hogue says.

NAHC takes it a step further. “NAHC will continue fighting for the industry to get relief for past claims denied,” it says in a statement.

In the meantime: “Agencies must clearly continue to collect narratives until the rule takes effect,” Hogue advises.

Once the narrative is nixed, complying with the other elements of the F2F requirement should be pretty straightforward, Hogue adds.

CMS previously changed the requirements to allow the agency to add a title and date if the physician forgets, Markette recalls. “Now, we are really only looking for the physician to certify they saw the patient in the appropriate time frame, which is all that the statute required in the first place.”

Minus the narrative, “this becomes a much simpler form — a few places to date and sign and not much else,” he cheers. If finalized, nixing the narrative “will go a long way to alleviating the problem with F2F.” 

Note: See the proposed rule at www.ofr.gov/OFRUpload/OFRData/2014-15736_PI.pdf. After its publication in the July 7 Federal Register, the rule will be available at www.federalregister.gov.