Home Health & Hospice Week

Home health agencies are hoping for some big changes to one troublesome provision in the 2011 proposed payment rule -- the face-to-face physician encounter requirement.

The mandate for the face-to-face encounter was in the Patient Protection and Affordable Care Act health care reform law enacted earlier this year. But the Centers for Medicare & Medicaid Services' version of the requirement is even stricter than the law requires.

For example: PPACA leaves the timeframe for the face-to-face encounter requirement open, but suggests six months. CMS instead wants the timeframe to be 30 days before or two weeks after the start of care in order to increase physician accountability, it says in the proposed rule published in the July 23 Federal Register.

The proposed rule also requires that the encounter be for the primary reason home care services are required and that physicians furnish "unprecedented" physician documentation about the encounter and why the patient meets homebound criteria. "We believe that CMS has gone beyond statutory intent" in those two provisions, says the National Association for Home Care & Hospice. (For more details of the face-to-face encounter proposal, see Eli's HCW, Vol. XIX, No. 27, p. 212).

The proposed face-to-face encounter requirement is riddled with problems for HHAs, industry experts say. To begin with, agencies have little influence over whether their patients make it to the doctor for a visit.

"It is absolutely ridiculous to place a requirement on home health providers for which they have absolutely no control," protests consultant Pam Warmack with Clinic Connections in Ruston, La. "How in the world is the staff of the home health provider supposed to ensure that the patient visits the physician and that the physician documents appropriately in his/her office records?" Warmack asks.

"We can make appointments for patients, but we can't ensure they keep them, that their transportation is reliable, that they feel well enough to make the trip, etc.," Warmack continues. "There are so, so many reasons that patients fail to see the physician despite the best efforts of the home care staff to make it happen."

The requirement will be "a particular burden on home health patients who are homebound and have difficulty leaving home," notes Judy Adams with Chapel Hill, N.C.-based Adams Home Care Consulting. "Patients who are bedbound would have to have ambulance transport," Adams points out. "Since it is not an emergency situation, Medicare will probably not pay for the ambulance fees, leaving these individuals to have to pay privately for the transport."

That's if patients can even get in to see the physician. In many areas, "it is becoming more and more difficult to find physicians who are accepting Medicare, much less see them as frequently as required by the rule," Warmack tells Eli. "I think access to care is going to be a major problem." "Even those [patients] who have recently been in the hospital were probably not seen by their primary physician, but by a hospitalist in the inpatient setting," Adams says.

"An extended timeframe for the certifying physician to conduct a face-to-face encounter is essential in the current health care environment where there are growing numbers of hospitalists, hospital-employed emergency rooms physicians, and a severe shortage of primary care physicians in the community," NAHC stresses. "Often patients are under the care of a specialist who will not follow the patient into general patient care in the home setting," NAHC explains And Medicare may not even pay physicians for those visits, experts worry.

Added work: Squeezing patients in for visits is just one of the problems physicians will face under the new requirements. CMS also will require them to create new documentation related to the visit and the patient's homebound status.

Under the proposal, the physician's documentation must "describe how the clinical findings of that encounter supported the patient's eligibility for the Medicare home health benefit," CMS says in the rule. "Specifically, the physician would document how the clinical findings of the encounter supported findings that the patient was homebound and in need of intermittent skilled nursing and/or therapy services," the rule says. And the physician must document it, even if her qualifying non-physician practitioner is the one who made the visit to "inform" her of the patient's condition, the rule proposes.

Watch out: "Getting the physician to do the required documentation will be a major challenge for many home health agencies," Adams forecasts. And the documentation requirement will be "one more reason physicians will be less likely to refer to home health."

Physicians "already feel overburdened with the home health paperwork," Adams points out. "And the number of calls and questions expanded significantly with the OASIS C process items that began in January."

Take action: While waiting for the final rule to come out in late fall, agencies can start educating referring physicians, other referral sources like hospital discharge planners, and caregivers about the coming regulation, Warmack suggests.

"Caregivers must be made fully aware of their responsibilities in making certain their family members keep their appointments," she urges. "The consequences of noncompliance must be spelled out in detail at the time of admission." "I would also recommend doing research into transportation organizations for patients who have no caregivers to fill that need," Warmack adds.