Home Health & Hospice Week

NAHC readies lawsuit over punishing face-to-face requirements.

Home health agencies are getting hammered on the face-to-face physician encounter like never before. Consider these expert tips to avoid crushing losses due to the issue:

1. Don’t let up on doc education. The Centers for Medicare & Medicaid Services and its contractors have largely taken a pass on training docs to fill out face-to-face documentation properly, home care experts charge. CMS is holding agencies accountable for physician practice, says Betty Gor-don with Simione Healthcare Consultants in Wes-tborough, Mass. That means you need to get out and educate them on how to furnish F2F documentation.

Agencies are at a disadvantage because phy-sicians aren’t the ones who get financially penalized if they furnish inadequate F2F documentation. But the docs’ patients won’t be able to access home care if the physician fails to provide documentation necessary for reimbursement, which may provide enough incentive to get them into compliance with the regulation.

2. Provide docs with forms. Use an F2F form with a certification statement, recommends clinical consultant Arlene Maxim with A.D. Max-im Consulting in Troy, Mich. For example, you can use the forms furnished for free by the National Association for Home Care & Hospice at http://caring.org/regulatory/home.html — scroll down to "Face to Face Encounter Templates."

Your forms should not just be checkboxes, Gordon warns. The physician needs to include a narrative statement on why her clinical findings support the need for skilled services and homebound status.

3. Double-check incoming documentation. Don’t just assume that because the doc filled in something on the form, that it will pass medical review.

Thanks to the high rate of medical review and resulting denials, "agencies are beginning to better understand what CMS and the MACs are looking for in the documentation," believes billing expert M. Aaron Little with BKD in Springfield, Mo. "However, the agencies can’t control what the physicians write or offer to them so this is a very difficult challenge, being held accountable for obtaining benefit qualifying information from unemployed physicians."

As awkward as it may be, you’ll need to be rigorous about returning insufficient documentation and asking for improvements — your reimbursement is likely to depend on it. "Physicians and agencies have created bad, bad habits," Maxim says. Now’s the time to break them.

In its education article, HHH Medicare Administrative Contractor CGS reiterates its advice to request the doc’s own "progress notes, visit notes, and/or history and physical (H&P)" to serve as the narrative. "If the required narratives regarding the skilled need and homebound status are contained in the progress notes/H&P, there would not be a need for an additional FTF form," CGS says.

However, it’s "very difficult" to obtain physician documentation that hits all the points required under F2F, Gordon believes. But this documentation can come in very handy when supporting your claim under appeal, she reminds agencies.

4. Comply with boundaries. Don’t forget that it is the physician (or his staff) who must fill out the F2F paperwork, not you. "Never, ever be tempted to fill out the information yourself," Maxim stresses.

This is where it sometimes gets tough for compliant agencies to compete with unscrupulous providers who will fill out paperwork for the doc. Referral sources don’t understand why one agency will do so when another won’t.

And of course, agencies that create entire bogus records for patients they never saw will look great under review. "Ironic that the providers that cheat will have perfect compliance and all others will suffer," observes Tom Boyd with Simione in Rohnert Park, Calif.

5. Take ADRs seriously. Don’t just ignore a random ADR or two because you don’t feel like you have time to respond to them. Likewise, don’t send off the most perfunctory of responses for the same reason.

Under the SMRC, requesting a small number of records "is a way for CMS to look at your face to face and then come up with a 40-to-150 claim review, since they know you have inadequate face-to-face documentation," Maxim warns. She urges agencies that receive ADRs from the SMRC to get the help of experts in responding.

6. Appeal. Maxim’s appeals department has "had some luck at the ALJ level," she says. But that may be of little help with the ALJ’s major backlog (see related story, p. 67).

"Your part is to continue to appeal these wrongful denials, all the way to the ALJ level," HCAF urges.

7. Support legal action. NAHC is readying a lawsuit over F2F, says William Dombi, the trade group’s VP for law. NAHC had hoped CMS would resolve the problems with F2F itself. But "the surge in F2F ADRs by the Supplemental Medical Review Contractor leads us to believe that litigation is our only option," Dombi tells Eli.

A lawsuit is warranted "since CMS has misread the requirements as given by the Affordable Care Act," Boyd maintains. While ACA requires the F2F encounter 90 days before or 30 days after the home health start of care, CMS’s requirement that the physician furnish a narrative, including clinical findings, supporting medical necessity and homebound status is a creation of CMS, critics say.