Home Health & Hospice Week

Agencies are fed up to here with the unrealistic F2F requirement, they say.

A solution for home health agencies’ face-to-face nightmare might be in the works — but that’s a big ‘might.’

The National Association for Home Care & Hospice’s Board of Directors has voted its ap-proval of NAHC filing a face-to-face lawsuit, re-vealed William Dombi, NAHC’s VP for law and Director of NAHC’s Center for Health Care Law, speaking at NAHC’s March on Washington policy conference March 24. The announcement drew ap-plause from the audience.

The straw that broke the camel’s back was the F2F audits launched recently by Supplemental Medical Review/Specialty Contractor Strategic-HealthSolutions, said Dombi in the conference’s Home Health Face-To-Face Forum. “How many contractors have to review it?” he asked.

The SMRC joins MACs Palmetto GBA and CGS in conducting F2F-focused reviews. Observers expect Strategic’s denial rates to be similar to the other MACs — in the 80 percent and above category. HHH MAC National Government Services ap-pears to be just launching its F2F medical review initiative, but industry veterans expect similar denial rates there as well.

Agencies Vent F2F Vexation To CMS

HHAs’ frustration with the F2F requirements showed in a separate session at the conference, the CMS Panel on Home Health Regulatory & Policy Issues. During the session, Hillary Loeffler from the Centers for Medicare & Medicaid Ser-vices put up a slide with an example of an acceptable F2F form — and was nearly laughed off the stage.

The example presented to the packed session showed a paragraph-length physician narrative composed of multiple full sentences. “Doctors will never do that,” called out one attendee. “You might as well move on,” lamented another.

“I understand there’s a lot of frustration about face-to-face,” Loeffler told the agitated audience. CMS hopes to work with providers and find a way to make the requirement workable, she added.

HHAs got more specific about their F2F concerns in NAHC’s F2F forum. Obtaining a sufficient F2F narrative ranked at the top of agencies’ problem lists. “We’re probably never going to get a physician to write this way,” NAHC’s Mary Carr said about CMS’s F2F examples that include three or four full sentences. Surgeons especially think — and write — “in staccato,” Carr observed in the forum.

When physicians compose the narrative in bullet points, MACs seem to deny the F2F no matter what those bullet points contain, one attendee complained in the forum.

No amount of physician education — which CMS has been slacking on anyway — will fix this problem, agencies contend. “Physicians know what CMS wants … they’re just not going to write it,” Carr said. “It’s an unrealistic expectation.”

Plus: Other F2F concerns ranged from medical reviewers losing F2F forms to docs signing the forms illegibly.

Pitfall: One attendee voiced frustration that when his agency’s claims made it through medical review for F2F, they then would get shot down due to homebound status or medical necessity.

And while agencies are having some success with the appeals process, it doesn’t offer them much relief considering the Administrative Law Judges’ two-plus-year backlog on cases, noted Chi-cago-based regulatory consultant Rebecca Fried-man Zuber in the forum.

Tip: If the F2F denial is due to a technical problem, such as the contractor claiming the F2F form is missing when you have documentation proving that it was included, you can use the much faster reopening process to seek resolution, advised Carr.

Hidden agenda: What many industry members worry is that CMS isn’t merely trying to safeguard the Medicare program with this requirement. Utilization and provider numbers have increased significantly since the industry’s IPS-era crash in the late 1990s, and CMS may be using F2F as a backdoor way to curb volume. In that case, they won’t be interested in fixing the problems with the measure.

Even if NAHC’s lawsuit planned for a mid-April filing succeeds, relief could be a long way off. The suit could take well over a year, at minimum, to process through D.C. federal court, Dombi explained. NAHC hopes instead that the suit quickly will bring CMS to the table to work on the requirement.

Dombi likened this suit to the one brought by NAHC in 1987, when one out of every three home health claims was being denied in medical review. That suit led to redefining homebound and skilled need under the benefit, with a collaboration between the industry and CMS on the terms.

What To Expect — And Not

HHAs should probably give up hope of seeing the face-to-face requirement eliminated completely, Dombi advised in the forum. As part of the Affordable Care Act, F2F is safe from elimination because lawmakers don’t want to open up the controversial law.

However, providers can hope for a change in the regulations implementing the law. Agencies and their reps have long contended that the law requires only that physicians document that the encounter occurred, not furnish the narrative component. A best-case scenario would eliminate the narrative completely. Smaller revisions to the requirement might be more realistic, however.

HHAs also might have to give something up to gain something, Dombi suggested. One place for concessions may be the window for the F2F visit to occur, he offered. Shortening the time period in which the visit may occur before the start of care to 30 or 45 days may be one solution.

In the meantime, agencies must expend their resources to comply with F2F as best they can and weather the medical review storm, experts advise. (See Eli’s HCW, Vol. XXII, No. 26, 29 and 31, and Vol. XXIII, No. 9 for F2F tips.) 

Note: For more information on F2F denials and how to avoid them, buy Eli’s Face-To-Face Doc-umentation Handbook 2014 online at www.codinginstitute.com/face-to-face-documentation-handbook-2014.html.