Home Health & Hospice Week

Physicians' inability or unwillingness to fill out face-to-face encounter paperwork correctly will mean a major home care access problem for beneficiaries and a huge financial hit for home health agencies.

That's what multiple providers and their representatives told Centers for Medicare & Medicaid Services officials at the National Association for Home Care & Hospice's annual March on Washington conference, in a standing room-only March 28 session.

The Visiting Nurse Association of Mercer County in Trenton, N.J. has spent four months intensively educating referring physicians on this issue, CEO Joanne Ruden told a CMS panel. The VNA has used powerpoint presentations, letters, examples, and repeat education to try to get the message about F2F requirements across to physicians.

After all that effort, the VNA is seeing 21 percent of its F2F paperwork not returned at all, Ruden told the CMS reps. And 77 percent of its F2F paperwork is returned, but not filled out adequately. That leaves just 2 percent completed correctly. "What am I supposed to do with that 98 percent?" Ruden asked.

Physicians are upset and angry about this requirement, Ruden added. That sentiment was echoed by other commenters during the session, who said that physicians have threatened to stop referring to home health over the requirements. In some cases, they're already doing so.

In North Carolina, agencies are seeing about 95 percent of F2F paperwork not returned or not filled in adequately, said a rep from that state. Physicians are just writing in things like "COPD" or "patient is old and blind" in the blank for the narrative, other providers reported.

Those types of descriptions won't meet the F2F narrative requirements, confirmed CMS's Lori Anderson in the session.

CMS seems to believe that "this is just an education issue and compliance will improve over time," Ruden tells Eli. "Even after extensive education this form will not work," she asserts.

Physicians don't really understand the definition of -- or documentation requirements for -- Medicare homebound in the first place, says consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tenn. And they don't feel like it's their job to learn it for these documentation purposes, says Gaboury, who attended the session.

It's not physician claims that are on the hook for this documentation, agencies say. So it's hard to get physicians and their staff to care about whether their documentation is sufficient.

Multiple providers asked CMS what physician education the agency has undertaken on this issue, because referring docs repeatedly tell HHAs that they have never heard of the F2F requirement.

CMS has made a big effort to educate physicians, including issuing MLN Matters articles, question- and-answer sets, notices in physician Open Door Forums and on listservs, and reaching out to national and state physician organizations like the American Medical Association, Anderson said.

One problem has been that the vast majority of CMS's F2F education materials are aimed at an HHA audience, not a physician one, points out Chicago- based regulatory consultant Rebecca Friedman Zuber, who attended the session. And they are posted to HHA listservs and on HHA websites.

Physicians are also confused about the significant differences between the HHA and hospice F2F requirements, says consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas. For example, physicians may get paid for their hospice F2F visit "under arrangement" with the hospice, but don't receive payment for a similar HHA F2F visit, says Boyd, who attended the session.

And for the hospice F2F requirement, physicians merely have to attest that the encounter occurred, as opposed to furnishing a narrative with clinical reasons justifying homebound status, Anderson acknowledged.

CMS may be putting out the message to physicians, but they don't seem to be hearing it, noted NAHC's Mary St. Pierre in the session.

Another complaint from physicians is that they can't get paid for doing F2F visits. Usually, a F2F encounter visit to the physician should be billable to Medicare for some other reason, Anderson said. In cases where it's not, physicians can offset at least some of the cost by billing for certification (G0180), she suggested.

CMS has been surprised that referring physicians haven't billed the cert and recert (G0179) codes more, Anderson noted. Unlike billing for care plan oversight, physicians just have to be able to prove they did the cert or recert to bill those codes.

CMS has tried to lighten agencies' and physicians' regulatory load for this requirement, but its hands are tied by the language of the Affordable Care Act law requiring the provision, Anderson maintained in the session.

However, the ACA actually suggested a sixmonth timeframe for the F2F encounter, while CMS first proposed 30 days, then settled on a 90-day timeframe, observers note. And the ACA merely says "the physician must document that the physician has had a face-to-face encounter ... with the individual." It's CMS's interpretation of that language that requires the doc to write a narrative justifying the patient's homebound status to fulfill the requirement, points out consultant Mark Sharp with BKD in Springfield, Mo., who attended the session.

While scheduling F2F encounter visits can be a hassle, it's really the documentation requirement that has physicians up in arms, providers report.

Bottom line: Providers will have to talk to Congress if they want changes in this requirement, suggested CMS's Latesha Walker in the session.

Congress implemented this requirement as part of an effort to curb fraud and abuse in the industry. But fraudulent agencies have no compunction about filling in the narrative for physicians or worse, providers pointed out. So the requirement is causing major headaches for compliant agencies that go by the rules, but no real trouble for agencies lawmakers may have meant to target.

Providers were hoping CMS might announce a delay to the April 1 enforcement deadline at the conference. But no delay is being announced yet, Anderson said.

NAHC is pushing ahead with its lobbying efforts to secure a three-month delay. "We need this additional postponement of enforcement of the faceto-face encounter requirements, or ... there are serious risks for tens of thousands of Medicare beneficiaries in terms of their access to care," NAHC Vice President for Law William Dombi says in the trade group's newsletter. "The doctors have said this is needed, the hospitals have said it's needed, case managers have said it's needed, AARP and other beneficiary organizations have said it's needed."

"In my 39 years in home care I cannot recall another issue of this significance that will create a nationwide access problem," Ruden says. "It is unreasonable to think that physicians want to complete more paperwork when they are overwhelmed with the sheer volume of what they already complete for home care and hospice referrals."