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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.

Your Rights as a Provider

It is not my desire to create drama but then again, I am not the one who took away your rights as a provider.

Your contract with Medicare is simple.  It states that you are qualified to perform services for home health and hospice patients and Medicare will pay you according to an agreed schedule.  Occasionally, they review clinical records and refuse to pay based on their assessment of your chart.  If you agree with their decision as is sometimes appropriate, so be it.  If you feel as though you disagree with their decision, you can appeal.

Sort of…..

Last week, I heard a rumor started by the National Association of Home Care and Hospice that the ALJ’s weren’t going to be docketing any more cases from home health and hospice providers.  I knew this could not be the case so I emailed Mr. Dombi at NAHC and he responded by sending a scanned copy of a letter from the Chief Administrative Law Judge, Nancy Griswold confirming this complete and utter lunacy.

For those of you who do not work in the world of appeals and do more important things like take care of sick people in their homes, let me explain this to you.

Imagine you did something else for a living.  Humour me and pretend that you are a roofer.  My insurance company who supplies 95 percent of your business  agreed to pay you to put a roof on my house and you did a fine job.   You shingled my home with materials that will withstand a category 5 hurricane and then you sent a bill and my insurance company politely declined to pay it.   Since the services were covered under your contract, the advance Roof Recipient Notice won’t protect you and I am held harmless while enjoying the sound of the rain on my new Cat 5 roof.

You take your complaint to the board of insurance and they tell you that you are right!  You did install at Cat 5 roof on my house but it doesn’t matter.  No payment is forthcoming.  Their reasoning is that in order to begin work, they had you sign a 30 page contract and on page 27, halfway down, it said that in order to be paid, you must initial the bottom of every page of the contract.  You only initialed 15 pages.

You decide the whole world of roofers and contractors has gone crazy and decide to take the insurance company to court.  The problem is there is no judge to hear your case.

So, I get the roof.  You get nothing and you have no rights.  The insurance company who signed a contract agreeing to pay you is sitting pretty with another satisfied customer under a Cat 5 roof and all you can do is work harder and faster to make up for the lost dollars.

That is exactly what is happening with Medicare appeals right now.  Payment is being refused for up to half of all claims at some MACs (e.g. Palmetto GBA, NGS, CGS) and you do not have any right to appeal denials past a certain point.  There is no person that you can talk to and you are completely unsure if anyone is actually looking at your records before rubber stamping  ‘denied’ on your claim. In short, they don’t give a flying flip that you had to pay your nurses or cover supplies.

When I work appeals, most of my work is done with the ALJ in mind.  If it’s good enough for them, it should satisfy the lower levels of appeals but often it does not.  The ALJ is the first human being that you can plead with to be reasonable. Except in desperate and extreme cases, the appeals process ends there.

Ms. Griswold confidently speaks to the increase in the number of denials being appealed but she does not speak at all to the increase in denials that are fully appealable or the rate of denials being overturned by Administrative Law Judges for the first two levels of appeal.   If the first two levels of appeals were performed competently, the workload at the ALJ would naturally fall as a byproduct of efficient, ethical and fair clinical reviews.

She makes a very valid point that the number of cases has increased overwhelming the ALJ’s but instead of addressing the huge percentage of denials that should have never been, she asks for ‘indulgence’.  It’s like pouring salt into a wound.

How dare Ms. Griswold ask for indulgence when almost half of the claims for home health have been denied by some MACs for grammatical errors relating to the F2F encounter documentation?   She wants to thank us in advance even though she has the responsibility to be well aware that her staff is ultimately overwhelmed due to the enormous increase in unfair denials.

I beg for your indulgence when I say that someone in Washington, starting with Ms. Griswold needs to have the courage to stand up for the good providers and quit playing political games with the healthcare needs of our elderly.

According to the HHS website, Ms. Griswold can be reached at:

OMHA Headquarters
1700 N. Moore St., Suite 1800
Arlington, VA 22209

Phone: 703-235-0635;   Fax: 703-235-0700


Make use of this information.  If you don’t speak up now, you may not be able to later.

Thanks to NAHC for sharing this information freely without regard to membership status. The content and sentiment in this post are mine alone and should not be attributed to NAHC or any other entity or person. 

Homecare vs Homecare

There is much philosophical talk about being divisive in our healthcare.  I don’t have a problem with being divisive.  This is my website and I can write what I want.  I am the senior editor – make no mistake. 

I do hold myself to certain standards, though and I think I may have fallen short on Monday and understated NAHC’s position on the Caps Limitation bill.   What I wrote was that both NAHC and The Partnership denied involvement regarding the introduction of the bill. 

In a nutshell the facts are:

NAHC – The organization that represents home health care and hospice on a national level has spoken out against the caps.   This is exactly what Bill Dombi of NACH wrote to me:

We do not support the episode cap and, in fact, have actively conveyed our opposition to Senate and House members.

The Partnership – A group of publicly traded homecare companies, plus a few stragglers, originally drafted the language in the bill but denies knowledge of how it was introduced.  This is what Eric Berger of The Partnership wrote in an email to me:

Like others throughout our community, the Partnership views targeted program integrity reform as a preferable alternative to further across-the-board cuts or the reimposition of cost-sharing that would impact innocent beneficiaries and their compliant providers. 

There’s only one sentence but if it were clinical documentation it would result in a denial.  Here are just a few of the questions it raises:

  1. Who are the ‘others’ in our community?
  2. Targeted Program integrity reform is what exactly?  Capping episode limits based on an arbitrary number determined by people who have never laid hands on a patient? 
  3. If there are innocent patients and compliant providers, does that mean that there are guilty beneficiaries?  Is that where the problem lies? 

As I stated in a post last week, there are some people who simply cannot write.  I cannot dance, remember?  The next email I received late Sunday night left no doubt about the position of the Partnership.  Again, from Eric Berger:

As for the Partnership’s plans with respect to this bill, we will not be taking any action on it — our total focus is on the rebasing and face-to-face regulations that pose a significant threat to our community. 

Initially, I was not going to make a big deal about this.  My concern is the bill itself – not The Partnership.  The members of The Partnership pay serious money to be a part of the elite group of companies that pay for lobbying efforts designed to benefit their companies.  Whether you like it or not, I do not believe there is anything illegal about it.   

So while it is very true that both NAHC and The Partnership deny having anything to do with the introduction of the bill, their positions on the bill could not be further apart.  I think that my original post would have been better if I had highlighted these differences.

Because honestly,  while I believe Eric Berger when he says The Partnership had nothing to do with the introduction of the bill, I worry about  his documentation skills.  He’s like a nurse who leaves the vital signs section blank and states the patient is stable.  We assume the nurse forgot to document the vital signs but it may be that the patient is dead.

Bill Borne, CEO of Amedisys Responds

Today, for the first time, I am going to present to you factually false information on my blog.  I do not know which information is false but I have received a lot of conflicting information from various places.

The delay in posting Bill’s response is a result of the fact that Bill’s initial response did not satisfy me in that I do not understand what he means about rebasing and then staying the cuts in 2014 and how this could possibly be good for the industry.  I fully agree that there is a lot on the financial and political side that I do not understand.  But within that email, Bill writes:

My colleagues, which are not an exclusive group, are working together with the whole industry to help stay the damage by working on positive messaging. These organizations are open to anyone who wants to step up to the plate in the industry and invest their time and money.

This came after the email from Keith Myers who said that the Alliance for Home Health Quality and Innovation are not in the business of lobbying.  I took Bill’s note on ‘positive messaging’ to be a euphemism for lobbying so I contacted him and gave him a chance to clarify his position.  Bill also received Keith Myers response to my original post which stated emphatically that no lobbying or legislative activity occurred.

That resulted in a phone call from Bill last Thursday.  During that conversation, he was adamant that Keith was one hundred percent correct.  He also said that perhaps I was confused.  There are and were multiple organizations out there and perhaps, I found information about the wrong group.  It is a sad fact for me that such a scenario is extremely possible so I found the lobbying reports forwarded them to Bill.  It was not my goal to discredit him personally so I offered him an opportunity to reconcile the lobbying reports with his position.  I did not hear back from him until late Friday afternoon.  See for yourself if he explains the lobbying reports.

September 30, 2011

To the Editor,

Last week, Reuters published an article that quoted me as calling for the government to provide home health providers greater clarity concerning reimbursement rates, in which the reporter noted that Amedisys and other publicly traded home health providers were lobbying Washington to accelerate the rebasing process. This article has generated a lot of attention, and I have received many questions seeking greater clarity concerning my comments. Accordingly, I wanted to take this opportunity to clarify my position regarding these matters.

As you may know, a report by the Moran Company from earlier this month analyzed the potential impact of CMS’ proposed 2012 reimbursement cuts and concluded they would lead to negative Medicare financial margins for 52.3 percent of all home health agencies in the U.S. This report can be found on

As the Reuters article reported, it is true that several members of the home health industry have formed the Alliance for Home Health Quality and Innovation dedicated to improving the nation’s health care system by supporting research and education to demonstrate the value of home-based care. However, the lobbying efforts referred to in the Reuters article were not, as stated in the article, undertaken by the Alliance, but rather by another group called The Partnership for Quality Home Healthcare which represents more than 1,800 community- and hospital-based, non-profit and propriety home health and hospice agencies nationwide and NAHC to develop innovative reforms to improve the program integrity, quality, and efficiency of home health care for our nation’s seniors.

Amedisys supports both the Alliance and the Partnership, and has also been a long-standing supporter of NAHC, which represents all home health care providers.

We invest our time and energy in these efforts to protect patient access to home-based health care for the more than 3.2 million Americans who rely on us. In doing so, we improve patient lives and the health of the Medicare system by keeping our nation’s chronically ill seniors out of the hospital and other more expensive facility-based settings.

The point I made to the Reuters reporter is that, despite the significant cuts in 2011 and 2012, our industry continues to face additional threats from many different sources, in the form of rate cuts, accelerated rebasing and calls for the implementation of co-pays, leading to great uncertainty about the future. Without a predictable and reliable long-term source of revenue, it is very difficult for any company—large or small—to form or implement a successful business plan or make the long-term investments necessary to support a healthy, sustainable organization.

In speaking with the Reuters reporter, I was speaking on behalf of myself and Amedisys only, not on behalf of the Alliance, the Partnership, NAHC or any of my colleagues. I personally support the effort to press Washington to provide our industry with a comprehensive reimbursement plan that we can be certain will be in effect for the long term. We deserve clarity on just how far the cuts will go. We need clarity so that we can plan ahead for mission critical business decisions such as hiring talent and investing in new clinical programs. If we leave rebasing totally up to CMS, each year through 2017 we will be forced to operate in uncertainty, taking us away from investing in patient care and instead worrying about which shoe will drop next. This uncertainty is simply not tenable—for any of us, or for our patients.

In my opinion, without the type of proactive initiative being spearheaded by the Partnership, we will certainly get an additional reimbursement cut in 2012, and again in 2014 when mandatory rebasing is implemented. The intent of my statement was to have the industry endure only one reimbursement cut, that we would have a say in and that would take place now, and that would be in effect for the long term, so we can operate our businesses with some certainty and confidence about the future.

I invite and encourage all home health care providers to help our industry by being active with any of the organizations formed to help increase awareness around the work we do helping and healing people each day.

We should not be divided. We need to have a joint effort to protect home health care. Our patients are depending on us to come together and protect their access to care.

Sincerely yours,

William F. Borne Chairman & CEO, Amedisys, Inc.

As mentioned previously, there is something factually false on this blog.  I am not in a position to know if Bill, Keith or the Lobbyists in Washington are the ones who have provided factually false information.   Bill and Keith can’t seem to get their stories to correspond on whether or not the Alliance actually engages in in any political activity or lobbies.   Read Keith’s very clear statement about the Alliance here.

If you read Bill’s statement carefully, you will see that he didn’t actually deny that the Alliance lobbied.  He said, “However, the lobbying efforts referred to in the Reuters article were not, as stated in the article, undertaken by the Alliance, but rather by another group called The Partnership for Quality Home Healthcare.”   So if the Alliance didn’t take on lobbying efforts referred to in the Reuters article, what efforts did they undertake?  Here is the lobbying budget for the Alliance of Home Health Quality and Innovation for the past four years.

This is the composition of the Alliance of Home Health Quality and Innovation from their form 990 filed in 2009.

On the Alliance’s 2009 Form 990 signed by , an IRS document required to be filed by all non-profits, the second page states, as attachment 2:  (bold lettering mine)

2009 was a transition year for the Alliance.  The Alliance has reorganized its working groups to address:  research, education of policymakers, internal and external communication, memberships, relationships with other professional organizations, quality and technology and innovation.  It also established working relationships with key policymakers at CMS, MEDPAC and other public and private organizations.  The Alliance has also held educational sessions for federal officials on the value of the home health benefit.

My understanding is that lobbying is an effort to gain political influence.  Truthfully, there is nothing wrong with that.  When a group of passionate people who openly state their purpose and do their best to persuade policy makers to make changes, the results can be amazing.  Going back to that little form 990 again, we see that simply joining a group does not give you an opportunity to facilitate change.

The Alliance shall have two classes of members:  once class of members with voting rights and the other class without voting rights.  Only members with voting rights may designate a representative who shall be eligible to be elected as a Director (it being understood that not all voting members shall be entitled to have a representative to serve as a Director).  The board of Directors may establish different dues categories and member designations in each class and shall otherwise determine all other rights and obligations of the members.

The Alliance also had to list its board members on the IRS form 990 in 2009.  This is taken from the IRS form 990 which exempts this organization from paying taxes.  Keith Myers signed the form.

Bill Borne Chairman and President
Ron Malone Vice Chairman
Val Halamandaris Secretary
Bill Yarmouth Director
MikeBayada Director
Chris McInnis Director
Keith Myers Treasurer
  • Once you get answers to some questions, even more arise.  Those that come to mind immediately are:
  • How can the lobbying reports be reconciled with the statements Bill and Keith made?
  • Is there a meaningful difference between ‘establishing working relationships with key policy makers at CMS, MEDPAC and other public and private organizations’ and lobbying?
  • Bill states the Alliance is open to all.  I have a whole lot of emails from home health agencies all over the country who state they never heard of it until last week.  If it is open to all, how much does it cost to join?  How much does one have to pay for voting rights?  What did the current members pay and is that public information?
  • Does NAHC have voting rights?  If so, on what scale?  If the voting rights of NAHC are proportional to Amedisys and LHC representatives, it stands to reason that the entire industry is not being represented proportionally.  If so, the name of the organization should be changed to, ‘Alliance of Really Big Home Health Companies’ .
  • If any topic arises that NAHC could be outvoted on by the large corporate entities, NAHC doesn’t belong in the Alliance, period.  That’s Julianne’s opinion.  No one else’s.
  • Do the members of NAHC know that their organization is part of a small group of very large players chaired by Bill Borne?
  • How much of NAHC’s membership dues went to pay the dues for being a member of the Alliance?
  • Bill proudly states that the Partnership for Home Heathcare represents more than  “1,800 community- and hospital-based, non-profit and propriety home health and hospice agencies nationwide and NAHC ….”  If you add up the number of agencies owned by Amedisys, LHV, Gentiva, Almost Family,Bayada and the VNA, I wonder how close the total is to 1800?  NAHC has 33,000 members according to their literature.   Which ones did NAHC choose to support?
  • Why is the Alliance for Home Health Quality and Innovation not listed on the NACH website under the affiliated organizations page?
  • Oh, and can somebody tell me who the Partnership for Quality Home Healthcare is?  The  information I know for certain is that they have a very large lobbying budget.  Nowhere on their website is the name of a manager, director, contact person, etc. mentioned.
  • Would the Avalere study emphasizing the benefits of home health have been more credible if the members of the Alliance hadn’t have paid for it?  It is understood in academic worlds that conflicts exist but conflicts of interest do not discredit a study nearly so much as the non-disclosure of said conflict.  By hiding behind the cover of the Alliance, a very expensive study was paid for by the largest home health care companies in the US.  I think that is relevant information.

As interesting as these questions are, nobody owes me an answer.  It is the agencies who compete against the larger publicly traded companies that need answers.  It is the 3,3000 home health agencies who are NAHC members that deserve to know these answers.

I encourage your comments.  However, since this is my domain, I could be held responsible for anything  published here.  I will withhold any comments that are overly insulting to any one individual or that make accusations that I cannot independently verify.  My goal is not to ‘attack’ any one individual or company.  My goal is to alert you to the fact that we have a limited number of large organizations, including NAHC that are making decisions for us all.

We have a ton of stuff to get done in the next couple of months in order to prepare for 2012.  But as far as this blog goes, it’s time to turn our focus back to what really matters.  We have to take care of our patients and keep them out of the hospital.  We have to endure cuts in payment but we will not compromise care.  We are nurses and given a roll of duct tape and a paperclip, we can bandage wounds, perform emergency tracheotomies, kill germs, and keep our patients quiet so we can provide the covered skill of teaching and training.

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