Home Health & Hospice Week

CGS denies 80% of claims for F2F.

Evidence of the flaws in the face-to-face physician encounter requirement continues to mount. But that isn’t helping agencies whose reimbursement is being siphoned off by the unreasonable requirement.

In edits of start of care episode claims from July to December, HHH Medicare Administrative Contractor CGS denied 80 percent due to insufficient face-to-face documentation, the MAC says in its March bulletin for providers. "Based on our review of the claims denied, most were attributable to two primary reasons," CGS explains. "1) Insuf-ficient documentation to support the need for skilled care; or 2) Insufficient documentation to support homebound status."

CGS says the most common problems were that:

• Documentation lacked any clinical findings
  
• Documentation read like orders rather than clinical findings (e.g., physical therapy for gait training, wound care, teaching); and
  
• Documentation included vague subjective clinical findings like "weakness," "dizziness," or "poor circulation" that was insufficient to support the need for skilled care or homebound status."

CGS breaks down the denials state by state. Agencies in Mississippi and New Hampshire fared the best with no claims denied for F2F, while agencies in Alabama, Hawaii, Indiana, Michigan, Minnesota, New Jersey, Oregon, Rhode Island, and Wyoming saw 100 percent of reviewed claims denied for F2F.

The 80 percent rate of denials is "a staggering number," observes clinical consultant Arlene Maxim with A.D. Maxim Consulting in Troy, Mich.

CGS’s high rate of F2F denials should come as no surprise, says billing expert M. Aaron Little with BKD in Springfield, Mo. HHAs are seeing "repeated denials for reasons related to FTF," Little notes. And fellow HHH MAC Palmetto GBA just released stats showing F2F denial rates in the mid- to high 70s (see Eli’s HCW, Vol. XXIII, No. 5).

"Actually, I am surprised [CGS’s F2F denial rate] isn’t higher," Maxim says. "The breakdown indicates there are actually some of these face-to-face documents getting through."

The high percentage of denials indicates that the F2F regulations implemented by the Centers for Medicare & Medicaid Services are flawed, "not that the providers are wrong," maintains financial expert Tom Boyd with Simione Healthcare Con-sultants in Rohnert Park, Calif.

"When in the history of Medicare has any one provider been absolutely dependent on payment as a result of another provider’s actions (or inaction)?" Maxim asks. "This is an egregious rule with so many unintended consequences."

"The F2F requirement is indelibly flawed in its conception and these unscrupulous audits target the best attempts of honest providers to comply with an undoable requirement," insists the Home Care Association of Florida in a recent message to members. "Home Health providers have no control over what the physician does or chooses not to do."

"I am clear on the reasoning behind assuring the patient is seen during the specified timeframes," Maxim allows. "However, we, as providers, have absolutely no control over another provider," she agrees. Hospitals often will not even allow an agency in the door, physicians refuse to accept documentation from another physician (i.e. hospitalist), and "the list goes on and on," she tells Eli.

HHAs Shoulder Doc Education Burden

It’s somewhat hard to blame physicians when CMS has expended so little effort in getting them to comply with the F2F requirement. "It has been up to the homecare industry to educate the physicians as an unfunded mandate — otherwise we don’t get paid," Maxim fumes. "It is absolutely ludicrous."

"How can the homecare industry force a physician to complete a document in a way that justifies payment when physicians are only being told to do so from providers like us?" Maxim continues. "The entire rule makes no sense."

Some HHAs suspect CMS of trying to thin the herd — reducing the number of agencies in the program and home health spending. HHA numbers currently are at their highest since the Interim Pay-ment System era.

Conditions today look much like those in the mid- to late 1990s, when IPS went into place, notes Nancy Allen with Solutions for Care in Jacksonville, Fla.

Under IPS, about one-third of agencies went out of business. Some industry observers harbor suspicions that CMS may be looking to achieve similar results again with F2F and other measures.

Note: See CGS’s F2F audit results at www.cgsmedicare.com/hhh/pubs/mb_hhh/2014/03_2014/PDFs/HHH_Bulletin_Mar14.pdf. For more information on F2F denials and how to avoid them, buy Eli’s Face-To-Face Documentation Handbook 2014 online at www.codinginstitute.com/face-to-face-documentation-handbook-2014.html.