Medicare Compliance & Reimbursement

Proposed mandate creates more problems than it resolves, commenters say.

Providers are skeptical that the 2013 home health prospective payment system proposed rule outlined by the Centers for Medicare & Medicaid Services will ease the burdens of the face-to-face physician encounter requirement in the foreseeable future.

CMS proposes two tweaks to F2F requirements in the 2013 proposed rule. One is to clarify regulatory language so that the home health agency, not just the F2F physician, can title the F2F documentation.

"Accepting F2F documentation that is complete with the exception of the physician titling the document is practical and saves the physician and agency time and associated administrative costs," praises Trinity Home Health Services in Livonia, Mich., in its comments on the rule.

The other is "to allow an NPP in an acute or post-acute facility to perform the face-to-face encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility, and allow such physician to inform the certifying physician of the patient's homebound status and need for skilled services," according to the proposed rule published in the July 13 Federal Register.

The NPP change "will improve the transition of patients from inpatient to home settings," praises AseraCare Home Health and Hospice in its comment letter. The comment period for the rule closed Sept. 5. But the revision makes it only "marginally easier to fulfill the face-to-face requirement," points out AARP in its comment letter. CMS needs to go much, much farther to fix the problems with this requirement, agreed numerous commenters that offered blistering critiques of the mandate.

Where Are The Physician Consequences?

HHAs' main hurdle in complying with F2F is that "physicians are unwilling or unable to document what is required for the narrative portion," the Texas Association for Home Care & Hospice tells CMS in its comment letter. "Many physicians refuse to complete the face-to-face and have stated they will no longer refer patients to home health."

Despite the many, many hours agencies have spent educating physicians on the requirement, numerous docs "still view the paperwork as duplicative and unnecessary based on the fact that other parts of the home health clinical record, such as the plan of care, provided detailed information to support physician certification of homebound status and medical necessity," explains Home Nursing Agency in Altoona, Pa. in its comments.

That leads to exhaustive and resource-intensive administrative burdens for agencies. Agencies spend precious time and resources tracking and circling back to documentation, HNA notes.

"The reality today is that agencies, sometimes up to a year, are needing to fax, re-fax, hand deliver, [and] pull documentation from electronic records in order to get the required detail in one document," recounts HealthEast Home Care in St. Paul, Minn.

These costly activities add no value for the patient or the program, commenters express. The F2F requirement "was established to target fraud but fails to do so," maintains the Vermont Assembly of Home Health and Hospice Agencies. "What it does instead is add unnecessary costs to the health agencies and added annoyance to physicians."

The current F2F requirement "focuses more on 'chasing paper' and diverts valuable resources away from patient care," Trinity argues.

HHAs Left Holding The Bag

After all that legwork, HHAs often can't manage to secure the necessary F2F documentation. Even after the requirement's been in place nearly two years, each day home care staff in charge of securing F2F documentation "are met with, 'I'm not filling out the form,' 'This is stupid,' 'Read the record,' 'Ain't it obvious,' 'Guess it's your problem,'" and more comments that demoralize employees, notes Mary Riha in Minnesota in her comments.

Current F2F regs contain "no accountability for standards of documentation or consequences for non-compliance," for physicians, rails HealthEast. The rule "continues to unjustly penalize Home Health Agencies from the perspective of regulation, compliance, fiscal accountability, and lack of physician compliance."

"HHAs have been placed in a difficult position of having to police physicians and face penalties for noncompliance while physicians, who have the responsibility for the completion of the face-to-face encounter and completion of the face-to-face certification form, are held harmless," reports the Hospital & Health System Association of Pennsylvania. As a result, agencies' cash flow is going down and accounts receivable is going up, HAP says.

"Making home health providers the 'documentation police' ... has actually resulted in physician groups setting up battle lines regarding who is responsible for documenting the encounter," Trinity laments.

When agencies can't get the documentation, they are left holding the bag financially. Agencies suffer "the inability to submit claims for countless episodes of care when physicians failed to document F2F encounters, or document correctly," notes the Ohio Council for Home Care & Hospice.

Stick To The Law

CMS went well beyond congressional intent in establishing the narrative portion of the F2F requirement, multiple commenters assert. "Congress legislated that in conjunction with the certification for home health that 'prior to making such certification the physician must document that the physician had a face-to-face encounter,'" says the Visiting Nurse Associations of America.

"The narrative statement requirements imposed by CMS go far beyond Congressional intent and add unnecessary burden to all parties," argues the National Association of Home Care & Hospice in its comment letter. "Other parts of the home health clinical record, such as the plan of care, provide detailed information to support physician certification of homebound status and medical necessity."

The poor construction of the F2F requirement is evidenced by CMS's continual need to tweak the requirements, multiple commenters said. "It is extremely burdensome to home health providers (who bear the brunt of the education and reeducation of physicians with every change) and frustrating to our physician and hospital care delivery partners to have to continually recalibrate as each needed degree of flexibility is added," notes the Home Care Alliance of Massachusetts in its comments.

But the changes -- and much more -- are necessary due to the rule's unreasonable burden on HHAs and physicians. If CMS fails to make necessary changes, it will court increased rehospitalization rates, emergency room visits, and nursing home stays as patients encounter home care access problems, commenters caution.

Note: The rule is at www.gpo.gov/fdsys/pkg/FR-2012-07-13/pdf/2012-16836.pdf.