Home Health & Hospice Week

Compliance is out of HHAs’ hands, industry leader insists.

With all the difficulties associated with the face-to-face physician encounter requirement, home health agencies knew they’d have an uphill battle in the new Probe & Educate medical review initiative. But the denial statistics may be even worse than expected.

Recap: In a MLN Matters article the Centers for Medicare & Medicaid Services released Nov. 9, it spelled out the P&E procedure, including that Medicare Administrative Contractors would review five claims from every HHA nationwide for compliance with F2F and other Medicare requirements (see Eli’s HCW, Vol. XIV, No. 40). If just two of the five claims have “errors” as identified by medical reviewers, HHAs must repeat the five-claim review cycle.

In data disclosed in a National Government Services J6 Provider Outreach and Education call, the HHH MAC says it denied 300 of 309 claims reviewed under the initiative so far, according to the National Association for Home Care & Hospice — a staggering 97 percent. About 40 percent of the denials were due to non-response to the Additional Development Request (ADR).

“While the data may only be a small slice of the universe that will ultimately develop, it is an early sign that CMS established an F2F documentation standard that is impossible to meet,” insists William Dombi, vice president for law with the National Association for Home Care & Hospice. “Home health agencies have been very focused on complying with the new F2F documentation standards after the disaster that occurred with the first version involving the narrative requirement. However, the new data shows that the best efforts of the agencies is not good enough in the eyes of the Medicare contractors,” Dombi observes.

Out of HHAs’ hands: No matter how hard HHAs try, they are often doomed to fail in complying with this requirement, Dombi tells Eli. “CMS should realize that a home health agency cannot be reasonably expected to achieve compliance with a subjective standard of ‘sufficient documentation,’ particularly when it applies to documentation controlled by a third party, the patient’s certifying physician,” he maintains.

“The smart and fair move for CMS would be to drop the existing documentation requirement, institute a new one that simply requires the agency to document the date of the encounter, and for Medicare to rely on a review of the whole patient record to determine whether care is/was necessary and that the patient is/was homebound,” Dombi concludes.