Home Health & Hospice Week

Guarantee: New contractor will review your face-to-face physician encounter documentation.

Despite an OIG report that admits home health agencies have no control over physicians’ face-to-face encounter documentation, you can still expect intense scrutiny on the topic — and frequent denials unless you get a handle on the requirement.

“If the certifying physician does not complete the documentation correctly, [the Centers for Medicare & Medicaid Services] can deny the HHA payment because the face-to-face requirement is a Medicare condition of payment,” the HHS Office of Inspector General explains in its recent report, Limited Compliance With Medicare’s Home Health Face-to-Face Documentation Requirements. “CMS holds the HHA financially accountable for ensuring that the documentation from the physician meets the applicable criteria,” the OIG acknowledges.

The OIG shot down one-third of claims it reviewed for F2F reasons (see Eli’s HCW, Vol. XXIII, No. 15). And you can expect even more drastic figures when the new Supplemental Medical Review/Specialty Contractor StrategicHealth Solutions conducts F2F reviews on every single agency in the nation this year, as CMS specifies in its response to the report.

The SMRC review will be layered on top of the already existing review from your local HHH Medicare Administrative Contractors. Those reviews have sometimes denied up to 100 percent of claims on F2F grounds.

Gird yourself for F2F battle by following this advice from the experts:

1. Implement or improve your F2F form. In its report, the OIG urges CMS to provide a standardized F2F form for docs to fill out. “Actually, I believe their recommendation to develop a standardized form is a very good idea,” cheers consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C.

A standardized form “will not only help with physicians getting it done correctly, but it will also decrease the confusion of having hundreds of different types of forms,” notes Indianapolis law firm Hall Render in its analysis of the report.

Secondary benefit: And any F2F form issued by CMS would “at least make it clear to physicians that this is something that has to be done per CMS, almost regardless of effectiveness of the form itself,” points out Washington, D.C.-based health care attorney Elizabeth Hogue.

But don’t expect to see a CMS-issued form any time soon, experts say. CMS agrees in its response to the report that it will “consider” using one, but notes that the use of a standardized document would limit flexibility. Even if CMS decides to adopt a form, the clearance process will likely be lengthy.

“While we all applaud whenever we can avoid another form, if there was ever a time when a form might have been helpful, this may have been the time,” Hogue exclaims.

In the meantime, you should come up with your own form to help guide docs in providing the necessary F2F information (see related story, p. 123, for form tips).

2. Educate docs. In the report, the OIG urges CMS to “develop a specific strategy to communicate directly with physicians about the face-to-face requirement.” Specifically, “CMS needs to provide additional formal training and outreach about the importance of completing the face-to-face document,” the OIG stresses. “Because HH MACs’ responsibility to conduct provider outreach does not extend to physicians, HH MACs are not directly training physicians. It is therefore incumbent upon CMS to identify ways to educate the physician community about the requirements.”

CMS agrees with the recommendation, but experts fear that the agency’s education efforts will fall far short of what’s required, as they have to date. If you want to bulletproof your claims on the F2F form, “agency administration must take this very seriously and … initiate appropriate processes for education of physician office staffs,” Laff advises. Remember, a physician’s support staff can put together the F2F documentation for the doc to sign, CMS has said in multiple questions-and-answers. That includes “extracting” the info from the doc’s medical record or generating the narrative from the electronic medical record (see Eli’s HCW, Vol. XX, No. 12).

Tool: Give docs examples of what would — and would not — pass medical review, particularly in the physician narrative supporting homebound and skilled need. (For examples to follow, see box, p. 124. For examples of language that won’t cut it, see Eli’s HCW, Vol. XXIII, No. 15.) 

3. Check returning F2F documentation. You can’t just tailor your form, train physician offices, and hope for the best. HHA administrators “must implement review measures internally so that F2Fs are ‘vetted’ when received from the MD’s offices,” Laff recommends.

Don’t leave the job half-done, putting your reimbursement at risk. “It is vital that home health agencies review records for initial certification periods for face-to-face encounter documentation that meets the requirements,” stresses Wachler & Associates in Royal Oak, Mich., in its analysis of the report. HHAs “should review the narrative portion of the face-to-face encounter documentation to confirm that it sufficiently describes the beneficiary’s homebound status and the reasons supporting the medical necessity of the skilled services.”

The time for such review is in a pre-bill audit, suggests Hall Render.

Bottom line: “To try to prevent these initial denials and/or have success challenging the denials during the Medicare appeals process, it is very important that the face-to-face encounter’s brief narrative meets the stated objectives,” Wachler says.

When F2F documentation isn’t sufficient, return it to docs for correction and “provide education where necessary,” Troy, Mich.-based law firm Fehn Robichaud & Colagiovanni says in its analysis of the report.

Consequence: If you have docs that won’t provide adequate documentation, you may need to discontinue accepting their patients, since it puts your reimbursement at grave risk.

4. Review all F2F elements. Although the physician narrative is the most common culprit in F2F denials, there are plenty of other F2F errors that torpedo claims too. Problems in the OIG review included missing certifying physician signatures, invalid or missing dates for encounters and signatures, and missing titles. Check for those technical items in your pre-bill audit as well.

5. Appeal. If you do encounter denials despite your best efforts, don’t give up. “Appeal denials to at least the ALJ level,” Hogue urges. “The only thing that got us any relief from [Recovery Audit Contractors] was the backlog of appeals.”

Don’t let the current backlog and ALJ wait time deter you. “Despite the backlog, providers must appeal, appeal, appeal,” Hogue stresses. “We want the backlog to get even bigger because of F2F denials. We especially want hospitals, but other types of providers as well, to be screaming about how they can’t get hearings because of the backlog of appeals of denials based on F2F documentation.”

6. Push for change. “The face-to-face en-counter process needs to be changed,” emphasizes LeadingAge, formerly known as the American As-sociation for Homes and Services for the Aging. “This change needs to reduce the administrative burden on both home health providers and physicians, improve compliance with documentation of home bound status and skilled need and continue to reduce the incidence of Medicare fraud,” LeadingAge says in its analysis of the report.

Support the push for change by lobbying your members of Congress and by rallying behind efforts like NAHC’s impending lawsuit against CMS over the F2F requirements. At press time, NAHC had not yet filed the suit. 

Note: The OIG report is at http://oig.hhs.gov/oei/reports/OEI-01-12-00390.pdf.