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Posts from the ‘face to face requirements’ Category

Face to Face–Your Results

A few weeks ago, you were invited to take a quiz on the home health requirement for face – to – face encounter documentation.  If you haven’t already done so, please go take the quiz now.

The results were interesting to say the least.  You know when a face to face encounter must be done and you are very clear about your (non) role in the creation of the document.  Where you fell off was in the questions regarding who signs the face-to-face document.  If your overall score was not what you hoped, rest assured that your colleagues are right there with you.

Here are some of the more interesting responses.

Less than 50 percent of you knew that if a patient died prior to the 30th day and a good faith effort was made for the patient to have a face-to-face encounter, you may still bill.  This is not a suggestion regarding how to get around those pesky MD’s who refuse to sign, by the way.


The question that was particularly disturbing was a true/false question inquiring if it was true that the same physician who signed the 485 must also sign the face-to-face encounter document.  If you answered that question correctly, you are among a 35 percent minority.  A full 65 percent of you answered it incorrectly. (Green is good, pink is bad – I did not choose the color scheme.)


Similarly, less than half of you knew that if the hospital documentation was used as the face-t0-face encounter it had to be labeled as such and the date of the encounter had to be included.  When you consider many of the discharge summaries, they often apply to the entire hospital stay.  A visit date must be identified and declared as THE day the encounter occurred.  image

Rest assured, other than these very three common reasons for denial, y’all knew your stuff very well. 

So what do these results mean? If I was paid by your agency to come in and teach y’all about the face to face encounter and after I left, you continued to get denied, would you consider me to be an effective teacher?

The truth is that Palmetto GBA is responsible for educating you on the face-to-face to requirements.  This is part of their contract with CMS. 

Here’s the part that keeps up at night.  If all of you were to learn exactly what a perfect face to face documents looks like and then you all taught ten people who in turn taught ten people, by the end of next week literally billions of people would know everything there is to know about the face to face document. 

And not one patient would receive better care because the physician forgot to label the hospital documents as the face-to-face document. 

Just sayin…  Palmetto GBA, take it for what it is worth but I respectfully suggest you might have a little more work to do in the realm of face-to-face document denials. 

Battle Scarred

war against fraud

Normally, I try not to be so very outwardly hostile towards CMS but lately, it seems as though the feds don’t really need to justify intruding on my privacy or the bank accounts of legitimate health care providers, so, whatever. The fact is that the face to face document has become the equivalent of a Weapon of Mass Destruction by CMS and their contractors.

You, as a provider, have a lot to lose if you do not honor the provider agreement signed with Medicare.  What everyone forgets is that Medicare signed the very same agreement which guaranteed you payment for rendering skilled care to eligible beneficiaries.

Rightly and wrongly, Palmetto GBA has been denying claims for months with no consideration of the care provided to patients.   This week, CGS announced it planned to follow in the footsteps of PGBA which will radically increase denials for those providers.

The abuse of the Face to Face requirement by CMS contractors has gotten so out of hand that it has become abundantly clear that they are looking for any reason to deny providers regardless of the care that eligible beneficiaries received.

To be clear, there have been agencies who paid a medical director to sign orders blindly for the sake of convenience.  There are other physicians, like Dr. Jacques Roy who sold his signature and his soul for money.  The intent of the document was to ensure that patients were seen by their physicians who were then willing to sign their name to a document stating the patient needed care and was homebound.

So the rationale was sound and initially, it was not much more than an inconvenience for agencies to get an additional document signed upon admission.  Beginning last year, the face to face requirement has been bastardized as a weak excuse to hold onto money that good providers earned providing skilled care to eligible beneficiaries.

There is not a day that goes by that I don’t hear from someone about a denial related to face to face document and more importantly, it is rare that a day goes by that I am not made aware of very real fraud.

I have no idea why Palmetto and CGS have decided to wage a campaign of hostility towards providers.   In the ‘good old days’ when FMR was about the worst thing that could happen to an agency, the solution was simple.  Document well and follow the guidelines.  Lately it doesn’t seem to matter how good or bad your chart is.

One physician wrote in the reason homebound section, the ICD-9 codes for Parkinson’s Disease and scribbled ORIF.  I get that the document did not meet all the requirements for a narrative.  Also included on the document was the patient’s age (85), the fact that he had PEG orders.  Perhaps I am reading too much into the information.  Maybe it is reasonable to believe that an 85 year old patient with Parkinson’s Disease, and a hip replacement could leave the house unattended to play bingo.   Or softball.

Another physician wrote the reason for home health was paralysis.  Skilled nursing was ordered for catheter care and so the claim was denied.  The MD did not realize the nuances of home health coding apparently and the claim was denied because we can’t fix paralysis.

We can’t fix lazy and stupid, either.   It certainly relieves Medicare contractors of the burden of reviewing records if a face to face is not completely accurate or grammatically correct and it has become abundantly clear that many of the records sent are not even read.

The sophistication of the Medicare IT has grown exponentially in recent years.  They are able to tell if the physician who signed the 485 is not listed as the patient’s physician in the database but they cannot see a Part B claim from a physician and determine that the patient was seen timely.  Do they really believe that all those patients admitted from the hospital were not seen by a physician?

Not one single Medicare beneficiary has received better care because of this insane demand on agencies.  In fact, time and resources that could be used to teach nurses about the new Diabetic protocols (bet you didn’t know they were published) or otherwise enhance the clinical skills of nurses are being devoted to getting the physician to document one encounter multiple times to ensure the agency gets paid.  In some cases, the agencies are simply completing the form for the physician’s signature.  They get paid.

I strongly encourage you to play by the rules but also to fight every single denial for a face to face to the level of an ALJ.  The days when the cost of appeal was taken into consideration when determining whether or not to fight it are now part of our rich home health history.  Fight everything until an ALJ or two sees how very abusive these practices are.

Don’t call or email me for a couple of weeks if you have something confidential to say.  I figure after about two weeks, the feds will see how very boring my life is and remove the wire taps. And try to find some time in between ADRs and running down face to face documents to, you know, take care of a patient or two.  Remember them?  Patients?  Elderly, lots of DME and a ton of pill bottles; none of which contain the pill she thinks she takes for sugar.

Please tell us about any face to face horror stories below or email them to me privately.  If you are a client and anyone asks who your consultant is, tell them Jnon Griffin or Lisa Selman Holman.  Just sayin….

The Gimme’s

There is nothing in the world that I hate to see more than the ‘gimme’s’ – you know those denials that should have never happened.  It is especially painful to see them in documentation that otherwise met all Medicare criteria.  The good news is that these are preventable.

  1. MD failed to date his signature. 
    1. To reduce these denials you do have legal avenues to pursue.  For 485’s, keep a stack of attestations statements at the desk of the employee who receives and or files the orders.  When she notices that a date is missing, instruct her to copy the 485 and bring it to the DON or marketing department for rapid return to the MD.  If you do this as soon as it is received, the MD will remember signing it and will be less likely to refuse to sign.
    2. On all other forms, reverse the Signature and Date lines.  Make the date line stand out. 
    3. Pay a bounty for all undated signatures found in the clinical records.  If your home health aides came in one weekend and found 40 orders without signatures and you paid them $25.00 for each signature, it would still be less than one episode.  Who do you want your money to go to?  Loyal employees or back to CMS after you worked hard for it.
    4. Look into electronic signatures.
  2. Missing documentation
    1. In some patients, a single visit note can downgrade a chart to a LUPA.  Worse, you cannot demonstrate that you followed orders.  If an order is missing for a skill, then the visits for the skills are discounted, as well.
  3. No end in sight for daily visits.
    1. If you are below age 40, you may not be familiar with this reg but it is indeed a regulation.  Any time a patient is seen daily by the nurse for a period of 21 days or longer, there must be an end in sight to skilled care.  The only exception is diabetic patients.  Consider a patient that requires daily wound care and you provide it every day for 60 days don’t get paid for it.  You’re looking at a denial of 8k to 10k.  That’s a lot of consulting hours that you could have received from us.
  4. Face to Face Documentation
    1. Write a letter to all of your physicians explaining very clearly this condition of payment.  Furthermore, advise the MDs that you are aware of other agencies who do complete the Face to Face documentation for their signatures and in doing so, the docs may be unwittingly participating in Medicare fraud. 
    2. For physicians who have been late and uncooperative with face to face documentation, send someone to the MD’s office with a blank form at the time of the next referral and wait for it to be completed and signed before admitting the patient.  If it takes too long, start practicing the violin or, if you are an accomplished violinist, the tuba.
    3. If an MD has not returned the form and you have no other independent verification that the visit was made, prepare an HHABN for the patient and discharge them.  Explain to the patient that they absolutely can continue home health care services but they will be responsible for payment as their physician has not met the Medicare Conditions for Payment.
    4. If there is independent verification that the visit was made – written instructions, a copy of a prescription, etc., turn it over to the agency administrator.  On admit, look for these things!
    5. Do NOT become violent with the MD.  Legislation is being introduced in several states that will relax the penalties for Doctocide if lack of Face to Face documentation is used as a defense but thus far none of the new laws have been implemented. 
  5. Unlicensed Staff
    1. This happens very rarely but it is a nightmare when it does.   If you find out that a physician was not licensed in your state and your state did not allow physicians from other states to sign orders, every patient you have admitted to that doc is unbillable.  Worse, state Medical Practice acts vary.  Do not assume that because you did something in VA that it is okay to do in Montana.  Look it up.
    2. Similarly, Registered Nurses and Therapists who admit patients and have allowed their license to lapse have created documentation which determined an episode payment that is not billable. 
    3. This happens so rarely but when it does, it can cause total devastation to an agency.  Worse, it is usually not an oversight but a nurse or MD who has not disclosed that their license has been revoked.  This is easy to fix by having all of your clinical staff run and print their own licensure verification at the beginning of each quarter.  Hold their patients if they do not comply.  Get the office to verify MD’s every 3rd referral or once a month, etc.

Effective this year or maybe last, (who knows anymore with all the changes in health care), any provider who receives money from Medicare in error has sixty days to return it.  Failure to do so will elevate that erroneous claim to the status of a ‘false claim’ and the penalty is triple the amount of the original claim.

I hate the Gimme’s but if I worked for  Palmetto or one of the other MACs I would love them.  Once an undated signature is found, reviewing the rest of the chart becomes unnecessary.  On to the next.  But remember, I hate the denials resulting from a ‘Gimme’ but not as much as the agencies who end up on focused review because of the Gimmes or the owners who must have that conversation about trade school vs college with their kids.

Mandatory Reading

Every day I work to help my clients provide better care at lower costs so that we can all make a decent living.   I have no issue with making money in healthcare.  In fact, I am proud to get paid for work that ultimately helps patients.  There is no law against making money.  That is not to say that there aren’t any laws that affect us.  If it has not come to your attention that healthcare is a highly regulated industry, then you are probably not reading this.  Finding the on/off button on the computer would require more observation skills than you have.

Just to be clear, let me clarify the following regarding Physician Face to Face Encounters in Home Health.

  1. The physician must write his or her own narrative.  Alternatively, he may dictate it and his staff may type it.  A qualified NPP may perform and document the encounter but the certifying physician must sign beside the NPP.  Make no mistake, you are not a qualified NPP.
  2. The Face to Face encounter is a condition of payment.  Failure to follow the conditions of payment may result in credible allegations of fraud.  Fraud may result in large financial penalties or jail and a great deal of embarrassment.
  3. The encounter must occur within 90 days prior to admission or within 30 days post admission.  This does not mean that you are committing fraud if the signed F2F is not on the chart within 30 days post admission.  If you sent the form out with the initial plan of care that went out late, it is very possible that the F2F will not be on the chart at day 30.
  4. On the other hand, if a patient was NOT seen within the time frame, you should discharge the patient using the appropriate documentation (ABN) and let the patient know why.  Be very certain that the patient was in fact seen by the MD if you choose to wait for it.  Alternatively, you could get your careplans out on time.
  5. When my clients’ referral sources steer their referrals to the agencies that don’t make them worry about ‘all the bureaucratic paperwork bulls***’, a competitive edge is created against which ethical agencies cannot compete.
  6. If a physician signs said bureaucratic paperwork and a visit had not been made, you have found yourself an accomplice in fraud.  Understand this.  The Feds want you more than the doc because even the wealthiest docs don’t bill as much as a home health agency does and it is not a condition of payment for MDs.
  7. The right FBI agent will not disclose that to the doctor.  Instead, the FBI will convince the MD that capital punishment is a very real possibility unless he or she rats you out.  Consider that referral source who will sign anything you put in front of him or her a potential witness in your next fraud case.
  8. If being morally superior is not enough incentive for you to follow the rules, then consider that while most people get away with it, some do not.  Those who do not will readily tell you that it is a good idea to follow the rules before you attract the attention of the Feds.
  9. If being morally superior is not enough and you are willing to take the chance of being on a federal radar, there is always the possibility that I personally will find out who you are.  If that happens, you will wish  you were caught by the FBI because I am not nearly so nice.  Ask Bill Borne.
  10. Don’t mess with my clients.  They are trying to survive by doing the right thing.

Chances are the people who circumvent the rules to make life easier for physicians and steer referrals away from your agency will never get caught. That’s the truth. Nobody has a policy or talks openly about it. Instead, bonuses and positions are contingent upon the amount of claims billed and so a real incentive to take shortcuts presents itself and pleading ignorance is a valid option.  If a visit was made on the day documented on the F2F, it would be very difficult to prove that the MD didn’t write the narrative.  So that leaves agencies with the choice of doing something that violates the conditions of payment and probably never getting caught or losing referrals.  Are you starting to get why my mood has gone south?

I help a lot of people who have done things resulting in the appearance of fraud.  I help people who have actually submitted fraudulent claims.  I have not ever nor will I ever help anybody submit a fraudulent claim.  I would like to tell you that it is because I am morally superior but the truth is, it just isn’t necessary to take even the smallest risk.  Sick people will always be around and their will always be ways for us to improve care.  In fact, if we did all that we were capable of, CMS and Congress would be at our doors asking us how we wanted our money – direct deposit or cashier’s check.

Do the right thing, y’all.  I don’t like being angry.  And remember, it is all about me.

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