Face to Face Is Changing for the Better [07-16-14]

Filed under: Industry Updates — Editor @ 1:28 pm

cmsannouncementOn July 1, 2014, the Centers for Medicare and Medicaid Services (“CMS”) published the home health prospective payment rule (the “Proposed Regulations”) for calendar year 2015. Importantly, the Proposed Regulations contain the biggest change to the “face-to-face” requirement to date. This article will explain proposed changes to this requirement.

Changes to the Face-to-Face Requirement

The Affordable Care Act requires, as a condition of payment for home health services, that a physician document that he or she, or an allowed nonphysician practitioner, had a face-to-face encounter with the patient (known as the “Face-to-Face” Requirement”). The regulations created by CMS to implement the Face-to-Face Requirement went above and beyond simply documenting the encounter and required that the physician include a narrative explaining how his or her findings supported the conclusion that the patient was homebound and the services were reasonable and necessary. Home health agencies (“HHAs”) have struggled to meet the unpredictable demands of auditors related to the Face-to-Face Requirement narrative.

CMS notes that non-compliance with the Face-to-Face regulations has proven very costly to the HHA industry. In its discussion of proposed changes, CMS states that the FY 2013 Comprehensive Error Rate Testing (“CERT”) report identified an improper payment rate for home health services of 17.3% or approximately $3 billion dollars due to insufficient documentation. CMS acknowledges that “[m]ost ‘insufficient documentation’ errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services…”. In other words, allegedly “insufficient” physician narratives on the face-to-face documentation cost the industry approximately $3 billion dollars in reimbursement. The CERT report provides concrete evidence that the Face-to-Face regulations are costing HHAs billions, even if the care is being provided appropriately.

Fortunately for those in the home health industry, CMS intends to modify its implementation of the Face-to-Face Requirement. Having acknowledged that that the narrative requirement is having a significant negative impact on HHAs, CMS proposes to eliminate the face-to-face narrative requirement.

CMS proposes that instead of a narrative, a patient’s eligibility for home health will be determined by reviewing the “medical record for the patient from the certifying physician or the acute/post-acute care facility…used to support the physician’s certification of eligibility.” This means that they will simply look to the medical record of the certifying provider. CMS acknowledges that this record should support the patient’s need for skilled care and homebound status.

To be clear, even though the narrative requirement will be gone, the Proposed Regulations would still require the patient to have had a face-to-face encounter, for the reason for which the patient is in need of home health, no more than 90 days prior to the start of care or 30 days after the start of care. The face-to-face encounter would have to be with a physician or an allowed non-physician practitioner. The physician or allowed non-physician practitioner would need to document the face-to-face encounter, including the date of the encounter. This appears to be a significantly simpler documentation requirement.

CMS’s Proposed Regulations remove language requiring the face-to-face documentation be separate and distinct, as well as the title and date requirement and the need for communication between the acute care and community physician in the case of discharge. These changes appear to open the door to making the face-to-face encounter documentation simply part of the current certification.

In response to home health industry concerns that physicians have no stake in face-to-face requirements, CMS is proposing that if a home health claim is determined to be ineligible for reimbursement because of face-to-face deficiencies, the physician would not be eligible to receive reimbursement for certification, recertification or care plan oversight. This should provide some incentive for physicians to properly complete face-to-face documentation.

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