Home Health & Hospice Week

HHAs can’t control physicians’ documentation.

Home health agencies face a Herculean task with face-to-face compliance. And even a Greek god may not be up to the job.

Results from two of the nation’s three HHH Medicare Administrative Contractors show a skyhigh 92 percent average denial rate for claims reviewed so far under the F2F-focused medical review initiative (see story, p. 82).

“The denial rates when documentation is reviewed indicate that the requirement and its implementation are mortally flawed,” insists Chicagobased regulatory consultant Rebecca Friedman Zuber.

“If 90 percent of the providers cannot meet the requirement, there is something wrong with it — and I say that not just as an industry consultant, but as a person who spent eight years running a regulatory agency,” says the former director of the home care survey program at the Illinois Department of Public Health.

It is “unfair they should lose payments due to a referring physician’s issue,” notes Lynn Olson of billing company Astrid Medical Services in Corpus Christi, Texas.

“There is a very high frustration rate among HHAs because they are held responsible for sending the F2F information in, but are fairly powerless to coerce the physician to give them what is needed to ‘fix’ the situation,” says Judy Adams with Adams Home Care Consulting in Asheville, N.C. “Until [the Centers for Medicare & Medicaid Services] holds the physician responsible to comply with the requirements, this will continue to be a difficult, if not impossible situation.”

Falling short: Even when physicians hand over their records, they are often insufficient for medical review purposes, experts lament. “I review a great number of clinical records and I am continually finding inadequate documentation on a F2F,” reports consultant Pam Warmack with Clinic Connections in Ruston, La. “Even though the providers are securing the clinic notes from the physician who conducted the encounter, the clinic notes don’t contain the documentation that supports the admission.”

Warmack’s findings are in line with the MACs’ she says. “I estimate that about 90 percent of the records I personally audit do not have adequate documentation to meet the F2F requirement,” she tells Eli.

Medical reviewers must see all five required elements (see story, p. 82), points out Sharon Litwin with 5 Star Consultants in Camdenton, Mo. One of the most likely missing pieces is the documentation support for skilled services necessity, Litwin relates.

When the homebound and medical necessity criteria aren’t supported by the physician’s note, it’s a problem because HHAs can’t dictate how physicians document their visits, experts criticize. (See story, p. 84, for ideas on ways to combat this common problem.)

More technical issues also plague the F2F medical review process.

Example: “One of the common issues that we have observed includes this scenario: agency has a FTF certification statement indicating a qualifying encounter by Dr. X occurred on 01/01/15,” illustrates billing expert M. Aaron Little with BKD in Springfield, Mo. “In the patient record there is documentation that an encounter occurred — a copy of an actual encounter note — but that note either indicates the encounter occurred by a different physician than Dr. X or it occurred on a date different than 01/01/15. In either of these scenarios the problem is that the documentation supporting the encounter does not correspond to what was certified as being the qualifying encounter.”

Another common missing piece is the physician record showing that the F2F visit is related to the primary reason for home health, Litwin says. HHAs can’t help with that element, the doc record has to stand alone on that point.

Agencies are caught between a rock and a hard place under the new requirement. “The HHA has all of the losses, but limited ability to gain physician cooperation in meeting the requirements,” Adams observes. “The physicians have no real skin in the game, so it is not an important issue to them and is a headache they do not want.”

Bottom line: “The F2F requirement is out of touch with the way the health care system works,” Friedman Zuber protests. “Rather than encouraging and supporting the involvement of physicians in the delivery of home health care, it is driving an increasingly wide wedge between providers and physicians. Home health care is about collaboration, not about a hierarchical approach to health care delivery.”