Home Health & Hospice Week

You may have some hard choices ahead.

Under Medicare’s new “Probe & Educate” medical review initiative for the face-to-face physician encounter, you could find yourself stuck on prepay medical review indefinitely.

Smart home health agencies will take these steps to increase their chances of defending against the P&E review and obtaining their reimbursement:

1. Educate staff. “Ensure personnel have a thorough understanding of the 2015 documentation requirements,” urges billing expert M. Aaron Little with BKD in Springfield, Mo. (For more details on the new F2F rules, see Eli’s HCW, Vol. XXIII, Nos. 43 & 44). For a claim to pass medical review, a physician’s note containing three elements must bepresent (see Eli’s HCW, Vol. XXIV, No. 3).

2. Educate physicians. Ultimately, the physician’s documentation will make or break your claim, says Chicago-based regulatory consultant Rebecca Friedman Zuber. Help them understand what needs to be in the record to ensure their patients can receive home care services.

Pointer: Remember, the certifying physician can sign and date information from the HHA into the record, the Centers for Medicare & Medicaid Services offers in MLN Matters No. SE1524.

And agencies might want to have their referring docs use the voluntary F2F form CMS has proposed. However, agencies and their representatives have taken issue with the form, saying it repeats many of the flaws of the now-eliminated narrative requirement (see Eli’s HCW, Vol. XXIV, No. 30).

The National Association for Home Care & Hospice identifies its “primary concern” with the form as “the amount of free text that it contains, specifically the items to justify skilled service and homebound,” the trade group said in comments on the latest version. “NAHC does not believe physicians will be more able to complete the template with the language and specificity that CMS seeks than when the physician was required to complete a F2F encounter narrative.” CMS is seeking Office of Management and Budget approval of the form, which NAHC expects in the next few months.

3. Set up F2F review processes. “Ensure appropriate controls are in place to monitor documentation compliance,” Little advises. You don’t want to realize the physician’s record doesn’t support the claim only when it comes up for review.

4. Make tough patient calls. When a physician won’t hand over his documentation or fails to furnish documentation that meets Medicare’s requirements, you have a decision to make. “My primary advice for agencies is to review the physician’s documentation as early as possible and refuse or discharge patients whose documentation doesn’t meet the standard,” Friedman Zuber counsels. “Err on the side of caution until we have some experience with what the MACs are going to do.”

Tailor the decision: “There will likely be variation across the MACs as there always has been,” Friedman Zuber adds. “Get as much info as you can from your MAC about how they see things.”

5. Make tough physician calls. If you have physicians who are habitually non-compliant, “make tough decisions about whether or not to take these physicians’ patients” altogether, Friedman Zuber advises. “Agencies should have a good idea of their financial vulnerability to denials based on the physician’s documentation and make business decisions accordingly.”

6. Plan for loss. HHAs are bound to face losses under the new F2F documentation requirements, Friedman Zuber predicts. “If you are a nonprofit, you may have to fundraise more to recoup uncompensated care,” she offers. “If you are a forprofit, you should be able to calculate your risk and make appropriate business decisions based on those calculations and your overall business strategy.”

7. Watch for P&E ADRs. Don’t face F2F claims denials because you weren’t aware of the Additional Development Requests for the claims. “Instruct billing personnel to watch closely for the ADRs to come,” Little urges.