Eli's Hospice Insider

Inconsistent messages keeping docs from understanding -- and complying with -- the face-to-face requirement.

Getting physicians on board for the new face-to-face encounter requirement is like herding cats, and it is hospice providers and other home care workers who are having to fill the corral.

Problem: When the Centers for Medicare & Medicaid Services' announced that it was delaying enforcement of the requirement until April 1, many hospices breathed a sigh of relief -- and their FFE efforts ground to a halt. But the enforcement delay has caused some confusion over the FFE start date, says Kathleen Anderson with the Ohio Council for Home Care and Hospice. "Some agencies thought that that April 1st was the start date."

And hospices have many other reimbursement, regulatory, and operational issues on their plates, so coming into compliance before the enforcement date wasn't a priority. In some cases, those other issues include some serious state budget threats, observes Joie Glenn with the New Mexico Association for Home and Hospice Care.

But CMS said in an Open Door Forum this February that it expected hospices and physicians to be getting into compliance with the FFE requirement leading up to April 1st -- not waiting until then to get started. Unfortunately, it's easier said than done. Here's the holdup:

By far, dealing with physicians is agencies' biggest FFE challenge, industry representatives agree. "It's the physician's responsibility to complete the FFE appropriately, but we essentially have to babysit the process through its entirety," says Brad Garpestad of Spectrum Medical Inc. in Great Falls, Mont.

Hospices are having to spend a lot of time just educating docs about the requirement. "Most of the physicians have had no clue about this new requirement," says Keith Ballenger with Adventist Home Care Services in Silver Spring, Md. That's despite CMS insisting that it has conducted a comprehensive physician education campaign.

Because agencies are having to educate physicians on their own, the docs are receiving an "inconsistent message" about the requirement, points out Marcia Tetterton with the Virginia Association for Home Care & Hospice.

For example: "Physicians have gotten mixed messages about when the rule actually took effect," says Peter Cobb with the Vermont Assembly of Home Health Agencies. "We contend despite the delay, the rule started Jan. 1. It is just enforcement that starts in April." Some agencies are telling physicians that they don't have to do FFE documentation until April 1, which is making it difficult for agencies who have already implemented their FFE processes to get physicians to comply.

"Getting out a consistent message has been a problem," Cobb laments.

The time and resources spent on education is a significant part of the administrative cost burden this requirement pushes onto hospices, notes Kim Foltz with Iowa Alliance in Home Care.

High physician and non-physician practitioner turnover is just going to compound the ongoing need for -- and cost of -- referral source education, notes Casey Blumenthal with the Montana Hospital Association's home care division.

Once physicians hear about the new FFE requirement, agencies are getting serious pushback from them, industry reps agree. "Many have commented that this is just another piece of paper and/or process that takes even more of their time," Garpestad says.

The FFE requirement mandates duplicative documentation, Foltz maintains. "The vast majority of the information required in the FFE documentation also exists in the plan of care," she tells Eli.

The requirement "adds additional and unnecessary steps to the process and access of care," Garpestad claims. "This regulation adds steps and roadblocks to a simplified process. It confuses all who are involved in the delivery and coordination of care, adds burden to physicians and beneficiaries, and ultimately the accountability is placed solely on the home health provider for adherence to this regulation."

But the requirement is largely out of hospices' hands. "The provider has little recourse in the assurance that this eligibility requirement will be met by both the beneficiary and the physician," Garpestad says.

The bottom line: "This is not something that home care created, it is yet another burden on all providers that just continues to drive up the cost of care," Tetterton concludes.