Home Health & Hospice Week

New OIG report urges CMS to implement standardized F2F form.

If your claims haven’t come under the microscope for face-to-face compliance yet, get ready. And the review won’t be coming from your friendly neighborhood MAC.

In a new report, Limited Compliance With Medicare’s Home Health Face-to-Face Documenta-tion Requirements, the HHS Office of Inspector General recommends that the Centers for Medi-care & Medicaid Services step up its oversight of physician F2F encounter requirements for home health claims. In a review of claims from 2011 and 2012, the OIG concludes that CMS’s oversight of the requirement was “minimal.”

Response: Many home health agencies can attest that their HHH Medicare Administrative Con-tractors have taken their F2F review up quite a few notches since that time period. For example, MACs have reported denial rates up to 100 percent in recent reviews (see related story, p. 119).

But MAC review alone isn’t enough for CMS. In its response to the OIG report, CMS officially reveals that new Supplemental Medical Review/Specialty Contractor StrategicHealth Solu-tions is conducting F2F review on every single agency in the nation. Agencies and their representatives had reported the onset of this review earlier this year (see Eli’s HCW, Vol. XXIII, No. 9).

“The SMRC will perform approximately five document-only reviews for every HHA in the country to validate that the most recent/valid face-to-face encounter is in the medical record,” CMS says in the report response. “At the end of this one-year service-wide review of every agency, CMS will review the final report by the SMRC and evaluate results and recommendations.”

Having all the review conducted by one contractor, rather than separate HHH MACs, will be beneficial, CMS contends in the report. “Utilizing one CMS contractor for this review allows CMS to have a centralized source of data, leads to consistency in the review process, and less variability in results.”

But not using a MAC to conduct this review is problematic, believes Tom Boyd with Simione Consultants in Rohnert Park, Calif. SHS is “fairly new to home health review and hard in their approach as we have seen in the south,” Boyd tells Eli. “They have been given their instructions by CMS without ever having to deal with the providers or normal claim processing like the MACs have had to.” SHS’s lack of a “‘feel’ of the industry will warp their approach,” Boyd worries.

Bottom line: “SHS will make dealing with the MACs seem like a nice experience,” Boyd laments. And don’t be surprised if CMS ultimately ends up choosing SHS as the nationwide Recovery Audit Contractor for home health and hospice.

“Increased oversight is not in the best interests of the agencies,” says Chicago-based regulatory consultant Rebecca Friedman Zuber. “They will lose money as a result of a CMS policy that puts them at risk for something they cannot control” — physician documentation.

“The industry is in the unfortunate position of having a requirement that providers have to meet without the tools to enforce and without the responsibility over the actual documentation,” observes In-dianapolis-based law firm Hall Render in analysis of the report.

CMS Agrees To Step Up Physician Education

Even the OIG acknowledges that HHAs have very little influence over F2F documentation. “HHAs are held financially accountable for failure to obtain the face-to-face documentation but have no authority to compel physicians to complete it either timely or accurately,” the watchdog agency says in the report.

A Kaiser Health News article on the report notes that until physicians and HHAs are financially linked, agencies will have difficulty obtaining proper documentation, according to Loren Adler with the Committee for a Responsible Federal Budget, a Washington, D.C. bipartisan organization focused on public education about fiscal policy issues. “If you don’t pay people to do things, people won’t do them. Doctors are people too,” Adler told KHN.

In light of agencies’ problems securing sufficient F2F documentation from physicians, the OIG issues another recommendation urging CMS to educate physicians directly on the home health F2F requirement.

CMS agrees with the recommendation, noting that it may use MLN Matters articles, web-based training that carries education credits, and a special Open Door Forum.

Too Little, Too Late On Doc Training?

CMS has maintained that it has communicated F2F requirements to physicians adequately in the past. But two of the four HHH MACs the OIG talked to noted that they had not reached out to physician communities, because they are responsible for training only home care providers.

Washington, D.C.-based health care attorney Elizabeth Hogue applauds the OIG report’s recommendation that CMS develop strategies to educate physicians. “But good luck, CMS,” she exclaims. Docs have picked up — and are allowed by many agencies to continue — frequent poor habits when it comes to F2F paperwork since the requirement’s implementation in 2011. “Now it is likely to be an uphill battle to teach physicians how to do it right,” Hogue expects.

Better doc education from CMS “is something that should have been done from the beginning,” notes consultant Lynda Laff with Laff Asso-ciates in Hilton Head Island, S.C.

Standardized Form Welcomed With Open Arms By Many

Usually, CMS trying to limit flexibility would be a bad thing. But when it comes to F2F documentation, it’s an acceptable trade-off to help agencies get into compliance with the requirement.

In its report, the OIG lists various ways in which physician F2F documentation is not up to standard (see related story, p. 114). To head off at least some of these problems, the OIG recommends that CMS consider “requiring a standardized form to ensure that physicians include all elements required for the face-to-face documentation.”

The OIG’s recommendation “to develop a standardized form is a very good idea,” cheers Laff. A standard form combined with increased doc education from CMS should improve agencies’ F2F problems at least somewhat, she expects.

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,” Hall Render notes.

But HHAs shouldn’t count on a form just yet. CMS agrees to consider such a form, but “the use of a standardized form would eliminate some of the current flexibilities that providers are afforded,” it says in the report. For example, “the certifying physician can currently use the clinical note or discharge summary,” CMS points out. However, such documents rarely contain all the elements required for an F2F statement, experts tell Eli.

Agencies thought CMS might already be putting the wheels in motion to develop a new standardized form when it announced an April 22 Special Open Door forum on physician documentation for F2F. But instead, CMS released a guidance document on how physicians should conduct and document the F2F encounter in their own records.

F2F Documentation Requirement Fatally Flawed

The OIG’s recommendations may lead to some improvement in agencies’ ability to comply if CMS implements them, experts agree. But the fundamental F2F problem will remain: inability to get the required documentation from physicians. “Physicians are generally too short in their descriptions and fail to link the condition to the need of services,” Hall Render summarizes.

“Medicare Payment Advisory Commis-sion reports show Medicare spending for HHA has declined from $19.4 billion to $18.0 billion and the cost reports coming in show the decline continuing,” Boyd says. “F2F can take credit for the bulk of this.”

F2F “is a way to take money from home health agencies and make the government look like they are finding all types of fraud because a few sentences were not written properly,” fumes one commenter on the KHN story’s website.

“If they want to restrict the benefit to save money, CMS should just do that instead of annoying doctors, villainizing home health agencies, and making seniors think they have benefits that they may not be able to access,” blasts another commenter. “The new Face-to-Face documentation rules force doctors to write letters to CMS according to a documentation standard that makes zero sense to them, or any thinking person for that matter.”

Bottom line: “The requirement that the certifying doctor should have an actual doctor-patient relationship is a good home health documentation requirement,” the commenter concludes. “The narrative rules that CMS made up are the true fraud.” 

Note: See CMS’s proposal for physicians’ “Electronic Clinical Template Elements of a Pro-gress Note Documenting a Face-to-Face Examina-tion for Home Health Services” at www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Electronic-Clinical-Templates/Downloads/HomeHealtheClinicalTemplateF2FProgressNote21914.pdf.