Home Health & Hospice Week

Working the kinks out of your face to face encounter processes is going to take a while, so you'd better get started before your Medicare payment is at stake.

Right before Christmas, the Centers for Medicare & Medicaid Services gave contractors instructions to delay enforcement of the FFE requirement for both home health agencies and hospices until April 1 (see Eli's HCW, Vol. XX, No. 1, p. 2). Regional home health intermediary Cahaba GBA notified providers of the delay in late December, and NHIC and Palmetto GBA followed with provider announcements early this month.

The delay is "good news" for agencies, since they "definitely need more time to get processes in place to comply with the new requirements," observes consultant Aaron Little with BKD in Springfield, Mo. "Most of the feedback we've received so far is that of a sigh of relief for the delayed enforcement, because additional time is needed."

HHAs are taking a variety of approaches to FFE compliance in light of the delay. Some agencies are moving full steam ahead with their FFE processes, some are testing out the new requirement, and some are taking a wait-and-see attitude altogether.

The latter is a mistake, warns Chicago-based regulatory consultant Rebecca Friedman Zuber. "This is not a delay in implementation, it is a suspension of enforcement," Zuber stresses. "I am advising providers that they must move ahead with implementation."

In other words: Agencies are still required to implement the FFE requirement, Zuber tells Eli. "They just have time to build up the compliance of the physicians before CMS starts to deny claims."

"The rule is still in effect," agrees the National Association for Home Care & Hospice. "This three-month enforcement reprieve provides an opportunity to test every aspect of the rule's operation."

HHAs should use the three-month "dry run" as a chance to iron out the FFE wrinkles before the payment stakes get high. This opportunity "is our best way to see if the rule can work without harming innocent beneficiaries and how it can work best," NAHC says. "But there will be no experience to rely on for that information unless providers work to comply with the encounter requirements during the three-month enforcement suspension period."

Don't expect a smooth road to FFE compliance. Many providers' processes will need time to evolve before identifying what processes work well and sufficiently meet the new requirements, Little expects. That's "especially due to the demand this requirement has on physicians."

Allot yourself plenty of time to get into compliance by the April 1 deadline, particularly regarding the content of the physician's FFE documentation. "Repetition is needed for physicians to acclimate their compositions of clinical findings" to comply with the regulations, Little predicts.

As an example, look to the hospice physician narrative that Medicare started requiring inOctober 2009. In the initial months of Medicare's implementation of that requirement, hospices saw gradual improvements in the content of the physicians' narratives, Little relates. "We suspect many providers may notice similar trends with the new home health requirement as the months progress."

Once again, it's going to be up to HHAs and hospices to do most of the heavy lifting of educating physicians on this new requirement. CMS is "really not doing what [it] should be doing to educate physicians," Zuber laments. "Again they are relying on home health agencies to do this, and it is just building more tension between the physicians and the agencies."

For many referring physicians, the new FFE requirement will be no big deal. "But in a significant number of situations, it may result in a loss of access to care for beneficiaries because the physician's reluctance to do what is required will force some agencies to turn patients away," Zuber worries.

Home care providers should educate their referral sources and the physician community on the new requirements, NAHC recommends.

Rely on tools: The new burden will seem lighter if agencies give physicians helpful tools to complete the FFE requirement, Zuber suggests. Particularly handy will be tools that help physicians complete the documentation.

Agencies "can't do the documentation, of course," Zuber notes. "But they can develop tools that physicians can use ... that will help them address what needs to be present" in the documentation.

A recent frequently asked question from CMS makes clear that it's OK to provide "lead-in phrases" in documents the agency gives to physicians. For example, a document can say "I had a face-to-face encounter on ____(date). The clinical findings support home health eligibility because:".

"The lead-in phrase is acceptable as long as the physician completes the description of how the clinical findings support homebound status and the need for skilled services, in his or her own words," CMS says in FAQ 10299.

Resource: Model physician documentation letters are available for free on NAHC's website at www.nahc.org/regulatory/home.html -- scroll down to the FFE sections. (For a list of other tools, see Eli's HCW, Vol. XX, No. 1, p. 2.)

Agencies also can use physician education sessions to share good news that has emerged about the requirement. For example, the FAQs have clarified that physicians don't have to document the FFE at the time of the encounter. Documenting the FFE from the patient record later is fine "as long as the face-to-face encounter occurs in the specified timeframe of 90 days prior to the start of care or 30 days after the start of care and the documentation is completed before billing," CMS explains in FAQ 10297.

And electronic documentation and signatures are also OK, CMS says in FAQ 10302. "It's nice seeing [these clarifications] clearly stated," Little says.

Remember: Don't fail to limit your education and training to physicians. You'll need to train your own staff as well, NAHC adds.