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Posts tagged ‘face to face encounters. medicare denials’

End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

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Face-to-Face Changes?

Many thanks to Tom Calhoun of Bayou Home Care for forwarding me the CMS update regarding proposed Medicare changes to the PPS system while I was out and about yesterday afternoon.   (Be sure to click on the link and watch the video on Bayou Home Care’s page.  You will understand why I am proud to be known a swamp rat).

Like everyone, I was excited to see CMS start to back off on the unclear, ambiguous and cumbersome requirements of the Face-to-Face requirement.  The proposed changes are as follows:

  • Eliminate the narrative requirement but the certifying physician would still have to document that a Face-to-Face visit occurred and include the date of the visit.  Since nobody can agree on the definition of a ‘narrative’, this is probably a good thing.
  • Medicare proposes the consideration of records from the certifying physician or discharge facility ONLY when determining eligibility.
  • Physicians billing for certification/recertification for home health services will be denied if a patient is found to be ineligible.

The requirement that only the physician or discharge facility will mean that we can no longer turn to specialists records or pharmacy and other providers of care to support arguments of eligibility or homebound status.  I’m not too worried but be very aware of this in the future should these changes come into law.

If you are interested in what your physicians bill for home health certification, check out   Propublica’s  Treatment Tracker and find your docs.   Most do not bill often enough for certification/recertification visits to suffer appreciably from this requirement but some do.

All of this sounds really good, huh? It is – if you are an agency who has never been denied for providing good care to an eligible patient due to a poorly constructed Face-to-Face document.

Word of Caution

I tend to be overly sentimental and my first response to this update was an outpouring of warm feelings towards Medicare.  Luckily, I forgot to post this last night and have had time to reconsider my emotional response.

The proposed regulations by Medicare, should they go into effect, will not address any denials that occurred prior to the changes.  Recently, Palmetto sent a memo to y’all reminding you that no matter when a patient was admitted, the Face-to-Face documentation must be included with an ADR.

In other words, these changes offer no avenue of relief for denials that have occurred in the past.  It also allows for limited denials related to the Face-to-Face document in the future if the start of care date occurred prior to the proposed changes.

The lawsuit filed by Bill Dombi, for NACH – your association – takes the position that the regulations written to satisfy the Face-to-Face requirement were never legal.  If NAHC prevails in the lawsuit, then agencies may have recourse for prior denials if all other criteria were met.

I emailed Bill Dombi to determine if I was understanding this correctly and his response was that I appeared to be correct.  That’s about all you will ever get from a lawyer without depositions, cataloged evidence, sworn statements and DNA – the appearance of being correct.   In this case appearance does count.

So, welcome the changes.  Rest comfortably knowing that there  is a little gang in congress who are willing to relax the requirements implemented by the Grammar Police.  This is a start – not the finish to the remediation of an unwarranted attack on home care for grammatical errors.

Under no circumstances, should you become complacent.  The denials that occurred in the past were unfair and new rules taking effect at a future date will not change that. Similarly, don’t overlook the significance of the proposed regulations as it is appears that someone in Washington is listening.

Again, Thanks to Tom and to Mr. Dombi for taking time out of their days to keep me informed.


Priscilla Demonstrating a Proper Face-to-Face Encounter.  She continues to work on documentation skills.

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

I have never been a big fan of associations and organizations.  I am not a joiner in general.  Specifically, I have been very frank about my feelings towards the National Association of Home Care and Hospice.  I believe that in the past they took on causes that benefited some agencies at the expense of others.  In many ways, it is almost impossible to be an organization representative of all agencies of all sizes in all parts of the country.

As of June 5, that changed.  William A. Dombi, attorney for the plaintiff – your association – has filed suit against the US Department of Health and Human Services.  NACH is challenging the requirements regarding documentation of the Face-to-Face encounter.  They allege that Medicare is enforcing the Face to Face encounter requirements in ways that were never intended and are not legal.  They note that these retroactive denials are made outside of the consideration of the care needed by the patient or the quality of the care rendered to the patient.

This is good stuff, y’all.

Because I was so outspoken and passionately against the position NAHC took in the past regarding other issues, I owe it to the Association (and to myself) to be as outspoken and passionate in my support of this lawsuit.

If NAHC asks anything of its members, please cooperate to the best of your ability.  If nothing else, send the board at NAHC responsible for approving the filing of the claim a note of gratitude.  This is one position that NAHC has taken that benefits all agencies, patients, and the Medicare trusts.

I can respect that.

MLN Clarification

Jennifer Barker, a dear friend and the administrator at Audubon Home Health knows me well.  She gets that I do not open emails without a compelling reason to do so and she made sure her I opened hers today.  The subject line was:  WTH?!?  If there had been even one more exclamation point, I suspect the email would have opened itself.

Her concern was with the most recent MLN guidance for the Face-to-Face document which was updated with examples on January 15, 2014.  I read it briefly and did not fully understand her concern until I went back to her email.

Before I tell you Jen’s concerns, go look at page 10 and 11 of the MLN guidance

Did you see it? 

Jen pointed out that apparently MLN matters doesn’t realize that home health agencies type up the plan of care.  In MLN’s defense, there is a line that states that MD ‘documents’ the face to face encounter on the plan of care but since there is no change in font or color, it appears as though the encounter documentation is part of the original information sent to the MD for signature.


So, I started looking some more.  The MLN matters document mentions a couple of times about the MD dating the signature of the face to face documentation.  Did that change?  Why on page eleven is it necessary for the MD to sign twice?  I’m just curious.  The Medicare Benefit Manual, chapter 7 pertaining to home health states:

The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.

There is certainly nothing at all wrong with a dated signature and by far, two signatures are better than none.  However, do not be misled into thinking that your face-to-face documentation is incorrect if your:

    1. Face-to-face encounter is documented on the plan of care which is signed and dated by the physician (in which case only one signature is required and that signature is dated)
    2. An addendum is attached to the plan of care documenting the the face-to-face encounter which is signed by the physician (a date is not incorrect but is not mandated according to the Benefit Manual).

The note on page 2 of the MLN matters information may contradict the manual although due to the sentence structure, I am not sure what the note actually means.  It reads:

Note: The homebound status of the patient and his/her need for skilled services must be written in a brief narrative, signed by the physician, titled “Home Health Face to Face Encounter”, and dated.  (Exactly what must be dated in that statement?)

Remember, these are the instructions that your referring physicians are receiving.  There is no point in contradicting them as a date will not invalidate the face-to-face documentation.  However, I do not suggest going back for a revision if a face to face encounter document does not have a dated signature.

Hey, I have an idea…..  Let’s focus on taking care of patients next week.  Any ideas of how we can help each other become better nurses?

New Kids on the Block


Strategic Health Solutions is a Medicare Supplemental Review Contractor.  If you haven’t heard of them yet, chances are you will.  They have been ‘encouraging’ agencies to send them clinical records with letters that read as follows:

Effective April 1, 2011 , Section 6407 of the Patient Protection and Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare Home Health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. CMS implemented the face-to-face encounter requirement of the ACA via the Home Health Prospective Payment System (HHPPS) Calendar Year rulemaking. The Final Rule states that documentation of the face-to-face encounter must be present on certifications for patients with starts of care on or after January 1, 2011 .

Office of Inspector General (OIG) work conducted, before the ACA mandate went into effect, found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home health care. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.980(b). Based on this information CMS has directed Strategic to perform postpayment review of Medicare Part A Claims billed for home health services.

As you well know, it is most unlike me to be argumentative but I googled ‘home health referral sources’.  As it turns out, the CDC information from 2010 is in stark contrast to the information provided by the OIG via Strategic Health Solutions.

referral sources

This graph states that providers who only offer home health services have 40 percent of their admissions from a hospital.  It says that 30 percent were from physicians but not that they were the outcome of actual physician visits so lets assume none of them were.  Sadly, the CDC’s 2010 report references 2007 data.

Lets move on to MedPac.  They write reports twice a year for the Congress about how much we are overpaid.  They increase our confusion by writing about how many episodes are preceded by a hospital stay but their data reflects 2010 so that’s a plus.  They say that 27 percent of initial episodes are preceded by a hospital stay and the average length of stay for those patients was 1.4 episodes.  That means that 38 percent of patients come from a hospital.

Neither MedPac or the CDC differentiate between patients  who were in the hospital seen by physicians who did not order their home health and those that did.  If a patient was from out of state, it might be that their personal doctor ordered home health or that a hospitalist saved that special joy for the primary physician.   This is important because it shows how accurate data could potentially be manipulated to paint an inaccurate picture of our industry.

In any event, I can say with confidence that at least 38 percent of patients were seen by a physician because that’s what happens in hospitals.  Doctors come write orders, nurses carry out the orders and the cafeteria always closes five minutes before you can get away to lunch.

So, we have huge discrepancies between the CDC, the OIG/SHS and MedPac.  Who are you going to believe?  My money is on the OIG because the CDC and MedPac do not have the authority to arrest me or monitor my email or phone calls.

So, after that long and rambling trip through the unfamiliar territory of numbers, we are back at the 30 percent mark referenced in the letter reproduced above sent by the OIG/SHS.  That leaves us with some disturbing facts.

We have an entity that looks like a RAC, walks like a RAC and quacks like a RAC but is really a Medicare Supplemental Review Contractor.

The RAC lookalike has noted that in 2010 providers did not adhere to guidance that was effective in 2011.

This non-adherence from 2010 constitutes NEW AND MATERIAL evidence that is being used as grounds to investigate home health care agencies for fraud.

And they will find it.   And it will not in any way, shape or form improve the care that our patients receive.

Note:   Pre-Nursing was the only curriculum that did not require math when I was in college which is why I chose nursing as a career.  Please feel free to correct any mathematical errors – politely, of course.