Home Health & Hospice Week

Can agencies obtain F2F relief instead of just a burden swap?

If CMS thinks it was doing home health agencies a favor by proposing revisions to the face-to-face physician encounter requirements, it needs to think again, scores of HHA commenters say.

Numerous commenters expressed approval of dumping the F2F physician narrative, but many blasted CMS’s proposal to rely on the physician’s documentation to determine eligibility.

In its 2015 proposed rule for the home health prospective payment system, the Centers for Medicare & Medicaid Services floated the idea of eliminating the narrative but instituting a mandate to verify eligibility by checking “only” the doc or hospital’s records (see story, p. 250).

“Our agency has no control over or knowledge of what a physician has in his or her files,” protests Patricia Remmers from Kansas in her comment letter in the rule. “The proposal suffers from the same problems that afflicted the narrative requirement… (W)e have no control over the documentation, but all of the risk of liability triggered by a claim denial.”

“I am concerned that reviews will be conducted and denials received based on documentation that is beyond our control and becomes reliant on physician documentation,” says a commenter from the Visiting Nurse Home Care & Hospice of Car-roll County in New Hampshire. “Our internal pro-cesses are vigorous and adhere to guidelines and regulations for the home health industry. Home health documentation identifies and supports the need for home care which may be missing from a less comprehensive review,” the commenter says in the letter.

“The new proposal, while well intentioned, requires that the physician’s clinic or hospital record adequately captures the appropriate face-to-face information to justify home health services,” notes Horizon Home Care & Hospice in Wisconsin in its comment letter. “The adequacy of their documentation will be determined at a later date, retroactively, by some form of audit. As a home health provider, I am not comfortable seeing patients whose care may cost thousands of dollars, not knowing if the reimbursement might later be recaptured because a physician did not document adequately in his or her records,” says Horizon’s Mary Flaynor. “Based on the face-to-face forms we receive today, I highly doubt that their records will be comprehensive.”

Records lacking: “The hospitalist and/or primary care physician’s notes in the medical record typically focus on the treatment of the illness that required a hospital stay, but not necessarily the post-acute services,” points out Atrius Health in New-ton, Mass., in its letter. In contrast, “the patient’s plan of care that is signed and dated by the attending physician includes information concerning the health and environmental conditions that exist when the patient is in the home.”

Under this proposal, “the home care agency would still be at risk for nonpayment if the documentation in the physician’s or acute/post-acute fa-cility’s records does not succinctly (as judged by CMS review) explain homebound and a clinical status justifying the home care benefit,” observes Crit-tendon Home Health in Michigan in its comment letter. “Teaching physicians how to document to meet Medicare requirements has been the basis of these difficulties since the inception of this onerous regulation,” the agency points out. “The home care agency has NO control over what/how physicians or NPPs document.”

CMS’s proposal to take back Care Plan Oversight payments from docs probably won’t help the situation much, Horizon’s Flaynor expects. “Many physicians in our market do not bill for care plan oversight; so there will be no incentive for them to create adequate documentation in their records,” Flaynor says in the letter. “In fact, physician care plan oversight reimbursement is so limited that I doubt any physician will change his or her practice to avoid losing care plan oversight monies.”

No-go: “Obtaining all potential documentation from the physician office prior to the start of care is a possibility but incredibly expensive and time consuming,” according to Horizon’s letter. “Additionally, it is likely to delay the start of care.”

Obtaining records probably isn’t even a viable option in many cases. “Physicians are not going to easily turn over copies of their records to support our services,” Crittendon says. “A physician has no vested interest in whether or not an agency is reimbursed for services.”

Bottom line: “HHAs do not exercise any control over the creation and maintenance of referring physicians’ records,” summarizes Maxim Healthcare Services Inc. in its comment letter. “Therefore, any requirement that would subject HHAs to repayment based exclusively on a review of physician records would perpetuate the same problem that the proposed rule attempts to address” with the elimination of the narrative. 

Note: See the proposed rule at www.gpo.gov/fdsys/pkg/FR-2014-07-07/pdf/2014-15736.pdf.