Medicare Compliance & Reimbursement

Warning: Pay attention to what’s in the mail.

The results of Medicare’s Probe & Educate review initiative are alarming to say the least. Only one in 10 claims reviewed passed muster. Heed this expert advice to avoid claim denials on the basis of non-compliance.

1. Prioritize F2F compliance. Home health agencies (HHAs) have a million requirements ranging from reimbursement to finance to operations to worry about, but this one needs to take a front seat due to its major reimbursement impact. Make F2F a priority, urges nurse consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Getting yourself into F2F compliance may require a major overhaul on both the clinical and billing sides, and you need to make sure you’re up to the task.

2. Educate yourself. You may think you know about F2F compliance, but your information may be incomplete or outdated as the Centers for Medicare & Medicaid Services (CMS) issues additional clarifications and guidance. Consult up-to-date resources to make sure you understand your obligations under the F2F requirements that took effect in January, 2015.

3. Focus on the 5 elements. In educating yourself and your staff on the requirement, make sure you understand the five items medical reviewers will be looking for and how you may obtain them for review, recommends Sharon Litwin with 5 Star Consultants in Camdenton, Mo.

Pitfall: HHAs often attempt to piece together information that does not follow the rules, Laff warns. The information can’t come directly from you; it must come from the physician’s record.

4. Understand when you can help. The doc or facility has to furnish three items all on their own — the visit date, physician or provider who made the F2F visit, and the reason for the visit. But you can furnish supporting documentation to the physician that substantiates the patient’s homebound status and need for skilled services, CMS and the MACs have repeatedly confirmed.

Remember: “The physician has to sign off on that information and make it part of the physician’s record,” emphasizes Judy Adams with Adams Home Care Consulting in Asheville, N.C.

5. Educate physicians. After you feel you have a handle on the F2F requirements, communicate with your referring physician offices to let them know exactly what you need, Laff advises. As with your own education, focus on the five elements the physicians must provide in their records to support your claim, Litwin advises.

6. Watch for ADRs. In revealing their Probe & Educate denial rates, MACs National Government Services (NGS) and CGS disclosed that failing to respond to the Additional Development Request (ADR) accounted for about 40 percent and 30 percent of their denials, respectively. It’s imperative for HHAs to “pay close attention to the mail for any requests for additional documentation,” an NGS spokesperson tells Eli. “To ensure proper payment, it is critical to respond promptly to these requests with all of the materials that are requested.”

7. Track physician responses. As part of your normal operations, you need to assign a staffer to make sure physicians submit their F2F records to you timely, experts advise.

Pitfall: Don’t wait until billing time or until you get an ADR to request the documentation, Adams warns. Request the notes for the actual F2F visit upon admission.

8. Review the physician records. “The problem the providers are having with F2F is that they are still not getting from the physicians the documentation to support the need for home care and an adequate description of homebound,” insists nurse consultant Pam Warmack with Clinic Connections in Ruston, La. “Even though the providers are securing the clinic notes from the physician who conducted the encounter, the clinic notes don’t contain the documentation that supports the admission.”

One problem: “Often a non-clinician is tasked with securing the physician’s office visit documentation. This non-clinician then files the documentation in the clinical record but no one is reviewing it to ensure it has adequate content,” Warmack warns.

You need a clinician going over the record to make sure it contains the five elements reviewers expect to see, experts urge. “This requires actual review of the documents by someone with a solid understanding of the F2F requirements, and not just a process for tracking receipt of a document from the physician,” Adams says.

9. Submit follow-up requests ASAP. If the record is inadequate, you need to request more information from the physician.

Don’t delay: “It is difficult at any time to get additional information from [the] physician,” Adams acknowledges. “But if you do not start requesting it until the bill is ready to be sent in (60 days after the start of the episode), chances are, the agency will not get responses from the physician.”

And don’t wait even later, until you get an ADR, to request information either, Litwin counsels. “At the time of the ADR, there is a slim possibility that [agencies] can obtain additional documentation from the physician’s record to support the F2F requirement,” she believes. Remember that physicians can’t backdate information for the record, she says.

Even taking these steps, agencies face an uphill battle, Adams laments. “The majority of the F2F issue [is] in the physician’s corner and in many, many situations, the physician is not willing to take the time to complete the information in a way that meets the requirements,” she says. “They are even more reluctant to add information or revise it to be acceptable to the MACs.”

10. Submit your summary to docs. When you review the physician F2F documentation and find it lacking on the homebound and medical necessity fronts, submit your clinical summary or other supporting documentation to the physician to sign into the record, Adams recommends. Then re-request the physician record to make sure it actually got correctly added. “The only way the HHA will know what has been written and included in the [physician’s] F2F documentation is to request a copy of anything the physician has beginning at the start of care,” she stresses.

You may consider making this step routine for every patient, instead of basing it on the physician’s record content, experts offer.

11. Turn down referrals. It’s painful, but not as painful as furnishing repeated unreimbursed care. HHAs will have to stop accepting referrals from physicians who don’t comply with the new F2F requirements, Laff instructs.

“While HHAs never want to turn down patient referrals, they must establish a policy of not accepting referrals or the conditions under which they will accept additional referrals from sources when there is a known situation that the physician will not provide the appropriate F2F documentation,” Adams advises.

12. Learn from your denials. The F2F requirement continues to be very murky for HHAs and physicians, maintains M. Aaron Little with BKD in Springfield, Mo. “What I would like to see from the MACs — the ‘educate’ that they are supposed to be doing [under Probe & Educate] — is what do they consider acceptable and why specifically are they denying the claims,” Little tells Eli. “I’ve yet to see actual examples from the MACs of why they are denying these claims.”

HHAs may obtain more information with the one-on-one education sessions that are supposed to be part of the P&E process, experts hope.