Home Health & Hospice Week

Add the cost of denied claims to the crushing expense list for face-to-face compliance.

Home health agencies are starting to see claims denials roll in for face-to-face non-compliance, report industry representatives. The "broadbased" denials seem to focus on the signatures for the plan of care and F2F documentation not matching, says Vicki Purgavie with the Home Care & Hospice Alliance of Maine.

Agencies have seen "a slew of denials by NHIC, citing code # 55HTB, with the notation 'Need Face to Face Encounter Certification Signed by the Same Physician who is Certifying the Plan of Care,'" explains Susan Young with the Home Care Association of New Hampshire. "Needless to say, this is a problem when a hospitalist signed the F2F attestation."

The denials aren't quite nationwide yet, says William Dombi, vice president for law with the National Association for Home Care & Hospice. But the review, which is conducted by "at least" two of the home health and hospice Medicare Administrative Contractors, is "absolutely" focused on the issue of F2F documentation, Dombi tells Eli.

HHAs have been "waiting for ADRs and audits to be the next shoe to drop," says Joe Hafkenschiel with the California Association for Health Services at Home. Now it looks like that's begun.

An early problem: "It also appears that the contractors are not using the same standards among themselves," Dombi says.

Denied claims may be the most serious threat to agencies' fiscal health under the F2F requirement, but it's far from the only one. HHAs are already facing "tremendous challenges" in complying with the reg, notes Tracy Wodatch with the Connecticut Association for Home Care & Hospice.

"Compliance is expensive as extra staff time is needed," says Peter Cobb with the Vermont Assembly of Home Health Agencies.

For example: "We've had to add a full time office staff member to comply with this regulation and make all of the follow-up calls," one Home Care Association of New York State member told the trade group in a survey conducted earlier this year. It's "very time-consuming and expensive."

"It takes a huge amount of time and personnel to obtain" F2F documentation, another HCANYS member responded to the survey.

"We have created a time-consuming tracking and follow-up system that requires about 0.5 FTE," a third HCANYS member said in the survey. "We have been 95 percent successful in compliance with the F2F requirement, but the administrative burden is significant."

"The biggest effect seemed to be on administrative/clerical burden, with many agencies assigning dedicated staff/meeting time to satisfying this requirement," HCANYS's Roger Noyes tells Eli.

The costs of such FTEs "are not reimbursed expenses, and will continue to cause significant financial burden to home care agencies," maintains Kim Foltz with the Iowa Alliance in Home Care. "The administrative burden is excessive."

Those arrangements have many costs. "Liaisons and intake RNs are spending more time tracking down the forms rather than seeking out new referrals," points out Keith Ballenger with Adventist Home Care Services in Silver Spring, Md.

One New York HHA had the extra expense of scheduling physician home visits for bariatric patients who couldn't readily go into the office.

And even once you get the physician's F2F paperwork, you have to scan it carefully for compliance and send it back if it doesn't fulfill the requirement, another agency bemoaned.

"Physician documentation ... tends to be incomplete at best," laments Jennifer Sorensen of the Minnesota Home Care Association.

That's assuming you can get referring physicians to generate and sign off on the F2F paperworkat all. In many cases, "the physicians are simply unwilling to sign the forms," reports Barry Cargill with the Michigan Home Health Association.

Some referral sources just " flatly refuse to comply," Wodatch agrees.

In Ohio, physicians are telling agencies "it is too much documentation to refer a patient to home health so therefore [they] are not referring," says Beth Foster with the Ohio Council for Home Care and Hospice.

And "some physicians are blaming home health for this extra burden," Cobb says.

Many agencies report referrals being down since January, reps say. Referrals for some Iowa agencies are down more than 30 percent, Foltz reports. But of course, you can't prove that the F2F requirement is the sole cause of the downturn, Hafkenschiel points out.

Still, home care referrals blocked by F2F red tape translates into reduced access to the benefit, says Kip Bowmar with the Kentucky Home Health Association.

Rural providers seem to be facing the toughest battles in complying with the F2F regulation, notes Marcia Tetterton with the Virginia Association for Home Care & Hospice.

"It is very frustrating that this was seen as a problem to be fixed across the country, when it is likely only in isolated pockets that physicians may be signing plans of care for patients with whom they're not familiar," says Casey Blumenthal with the Montana Hospital Association: An Association of Montana Health Care Providers. "This is just not an issue in a state like Montana, so all it does is create extra burdens for HHAs and their docs."

"This makes an already hard job delivering care in rural areas that much harder," said one HCANYS member in the survey.

The F2F job might also be harder for nonprovider- based agencies.

Hospital-based providers whose institutions are enforcing the rule are at an advantage, another HCANYS member said in the survey. "None of the docs really want to do it, but our success rate is very good."

"Our hospital-based/owned physicians seem to do an OK job, but that's  t," Foltz agrees.

But that isn't true across the board. Some hospitals aren't requiring the documentation and are just saying they won't refer to home care, Wodatch points out.

For instance: Docs seem confused that a non-physician practitioner may complete the F2F encounter, but can't sign off on the documentation, Wodatch says.

The problem is compounded in states like Ohio that already have F2F Medicaid requirements on the books. When the Medicaid requirement took effect in February, "there was group of physicians that voted to only fill in the Medicaid check box form and not the Medicare required narrative," Foster reports. "It seemed that physicians thought there was a choice."

And sometimes hospital referral sources are confused by providers who offer to "find a way around" F2F requirements, Sorensen reports. That leaves "quality providers who adhere to the regulations without those referrals."

The bottom line: "Our members continue to experience struggles with the face-to-face regulatory mandate and it is getting no easier," Cargill says. "While home care agencies are doing their best to comply... the mandate is ... simply an unreasonable regulation to place upon the agency and should be abandoned. It places the agency to unreasonable liability and increases the cost to collect for services."