Medicare Compliance & Reimbursement

F2F here to stay for a while.

The face-to-face encounter is necessary to reduce fraud and abuse in home health utilization, says the Centers for Medicare & Medicaid Services (CMS). These problems have decreased since the face-to-face physician encounter requirement took effect, CMS says. 

When CMS proposed to eliminate the overwhelmingly troublesome physician narrative F2F requirement in July, home health agencies were overjoyed. But in its place, CMS proposed to “review only the medical record for the patient from the certifying physician or the acute/post-acute care facility (if the patient in that setting was directly admitted to home health) used to support the physician’s certification of patient eligibility,” according to the rule. “If the patient’s medical record, used by the physician in certifying eligibility, was not sufficient to demonstrate that the patient was eligible to receive services under the Medicare home health benefit, payment would not be rendered for home health services provided.”

HHAs and their representatives blasted that requirement in their comments on the rule. But the many criticisms of the rule were to no avail, agencies discovered when CMS issued its PPS final rule Oct. 30. CMS insists in the final rule that it is not going beyond congressional intent when requiring a narrative or the physician record review. 

“We believe that our policy is consistent with the text, structure, and purpose of” the Affordable Care Act, the agency says in the rule published in the Nov. 6 Federal Register. “As a condition for payment, [the ACA] requires that, prior to certifying a patient’s eligibility ... the physician must ‘document’ that the physician himself or herself or an allowed NPP had a face-to-face encounter with the patient. The statutory text does not specify what the statutory term ‘document’ means and we believe it is reasonable to interpret the requirement to ‘document’ the face-to-face encounter as requiring the certifying physician to explain why the Medicare beneficiary is homebound and in need of skilled home health services.”

Stats: In assessing the impact of F2F, CMS admits that utilization has decreased. The year before F2F implementation, there were 6.8 million Medicare home health users. That number dropped to 6.7 million in 2012 and 2013, CMS reveals. The percentages are more noticeable in higher-use states. Texas saw utilization drop 12 percent in that time period, and the top five states (Texas, Florida, Oklahoma, Mississippi, and Louisiana) saw utilization decrease 8 percent.

But CMS maintains that the change is small and only occurs in some states. And the agency implies that F2F may be reducing utilization in those states by preventing fraud and abuse. Those five “continue to be among the states with the highest utilization of Medicare home health nationally,” CMS says. And “Texas is one of the states that has areas with suspect billing practices.”

Texas: “If we were to exclude Texas from the national average … there would be a 0.13 percent increase in number of episodes between CY 2010 and CY 2013 rather than a 1.8 percent decrease as observed at the national level,” CMS says. “The number of home health users would increase 2.8 percent compared to the national average with an increase of 1.5 percent.”

There were other changes in those years besides F2F, CMS adds — new therapy reassessment requirements and case mix recalibration, to name a few. Any utilization changes “cannot be solely attributable to the implementation of the face-to-face encounter requirement,” CMS says. But it “could” be a “contributing factor,” the agency allows.

You’re on the Hook for Doc Records

Following its lengthy rationalization in the rule, CMS finalizes its F2F provisions as proposed.

Exception: Docs will still have to provide a narrative in one case, as proposed. “For instances where the physician is ordering skilled nursing visits for management and evaluation of the patient’s care plan, the physician will still be required to include a brief narrative that describes the clinical justification of this need as part of the certification/re-certification of eligibility,” CMS says in the rule.

How the new process will work: “We will require documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of home health eligibility,” CMS spells out in the final rule. “We will require the documentation to be provided upon request to the home health agency, review entities, and/or CMS.”

More work for you: It won’t be up to the physician to respond to record requests — you’ll have the pleasure of obtaining the records from the doc. “HHAs should obtain as much documentation from the certifying physician’s medical records and/or the … facility’s medical records … as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria have been met and must be able to provide it to CMS and its review entities upon request,” CMS instructs in the rule. “If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided,” the agency warns.

CMS “placed the burden of ensuring appropriate documentation squarely on home health agencies,” laments the Visiting Nurse Associations of America (VNAA) in a release. “VNAA believes the final rule will not provide relief to home health agencies responding to aggressive Medicare auditors and that a further increase in payment denials could be a result of the new requirement that home health agencies obtain a physician’s patient medical record as justification for face-to-face documentation.”

Having the doc responsible for furnishing the records to HHAs under regulation may be somewhat helpful, the National Association for Home Care & Hospices (NAHC) notes in its analysis of the rule. But it could still prove problematic, NAHC worries.

Slight improvement: A small piece of good news is that “CMS will permit HHAs to provide their record to the certifying physician so that it can be included in considering whether sufficient documentation exists to support the certification,” NAHC adds. That was not included in the proposed rule.

After numerous vociferous comments about how physicians won’t be motivated to furnish the documentation, CMS gives this warning in the final rule: “Again, we want to remind certifying physicians and acute/post-acute care facilities of their responsibility to provide the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit. Certifying physicians who show patterns of noncompliance with this requirement, including those physicians whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as through provider-specific probe reviews.”

In other words: Not only will home care referrals bring docs more paperwork; they also could bring down wide-ranging medical review. Physician “claims subject to increased review may include services unrelated to the home health claim being reviewed or the beneficiary who was referred for home health services,” CMS says.

Plus: CMS also finalizes its proposal to deny payment for physician claims for certification/recertification of eligibility for home health services (G0180 and G0179) when the HHA claim itself was non-covered because the cert/recert was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit.

Even though most HHA commenters said this change was useless as a motivating factor for F2F and would prove an annoyance, CMS proceeds with the provision. “If there are no Medicare-covered home health services, these codes should not be billed or paid,” the agency maintains.