Short Takes On News & Events

Incomplete Face-To-Face Doctor Exams Put Home Health Agencies In Tight Spot

By Lisa Gillespie

April 18th, 2014, 5:00 AM

Medicare is paying billions of dollars to home-health providers without adequate documentation of patients’ needs by doctors, according to a new report by the Department of Health and Human Services Office of Inspector General.

The cost of caring for homebound patients is rising, and the government is trying to get a better grip on spending by requiring doctors to certify — with face to face examinations — Medicare beneficiaries’ eligibility for home health services, including intermittent skilled nursing care, physical therapy, speech therapy and part-time home health aide services. The OIG estimated that $2 billion in inappropriate payments were made in 2011 and 2012 because of inadequate compliance with the rule.

But home health agencies, which billed Medicare $19.5 billion for these services in 2010, view the rule as burdensome and vague, and worry it will impede in their ability to deliver care.

Beatriz Lamb, regional director of home health care and hospice for Franciscan St. Elizabeth Health in Indiana, said that they give care to around 120 patients and juggle documentation from about 80 doctors. “It does create delays in care, we can’t afford to go out without a face-to-face [certification] in hand and I don’t have leverage to get it done if I’m already seeing the patient,” Lamb said.

The face-to-face rule results from a provision of the Affordable Care Act and is designed to reduce inappropriate Medicare payments for home health services. The OIG’s assessment found that of the claims that required face-to-face encounters, 32 percent did not meet the Centers for Medicare & Medicaid Services rules on what doctors must document, and should not have been paid. Home health providers worry that CMS could later try to recover these overpayments.

The rule requires that certifying physician must fill out documentation that includes the physician’s title, signature and date of the face-to-face encounter. It must also include a brief narrative that describes that patient’s clinical condition and the way in which the patient’s clinical condition supports his/her home-bound status and the need for care.

Federal fraud fighters have increasingly stepped up scrutiny of the home health industry because of the sector’s rapid growth. In 2012 alone, 257 new home health providers began billing Medicare. Meanwhile, spending on home health has increased by 89 percent since 2002. These agencies tend to have greater profit margins than that of other providers, and patients who use them don’t face cost-sharing requirements.

Home health providers say the incomplete paperwork isn’t necessarily an indicator of fraud or that services aren’t necessary. “The fact that you can’t get the narrative doesn’t mean that person shouldn’t get the care,” Lamb said.

For example, Lamb is currently in the second round of appeals in which her company is seeking payment for services the Medicare contractor initially denied because the claim’s face-to-face the narrative was deemed incomplete.

Physicians sometimes fall short with the paperwork because they don’t get paid to certify the face-to-face encounters, nor do they have contracts with home health agencies to coordinate patient care.

But filling out the forms correctly is in doctors’ best interests, said Kent Moore, a senior strategist for physician payment at the American Academy of Family Physicians. “Following these documentation requirements may determine if that home health agency remains willing to work with you. Following the directions may ultimately help you and your patients,” he said.

To improve compliance with the face-to-face requirement, the OIG recommends that CMS:

  • Develop a strategy to communicate directly with physicians about the face-to-face requirement, including additional formal training and outreach.
  • Create a standardized form to ensure that all required components are included by a doctor. The most commonly missing element OIG found was the signature of the certifying physician.
  • Put in place an enforcement mechanism to make sure home health agencies are turning in appropriate documentation. Relying on medical record reviews to ensure home health agencies are meeting the requirement isn’t sufficient.

Even if CMS implements changes, until physicians and home health agencies are financially linked, it will be a hard sell to get proper documentation, said Loren Adler, research director for the Committee for a Responsible Federal Budget, a Washington, D.C.-based, bipartisan organization focused on public education about fiscal policy issues. “If you don’t pay people to do things, people won’t do them. Doctors are people too,” he said.

4 Responses to “Incomplete Face-To-Face Doctor Exams Put Home Health Agencies In Tight Spot”

  1. evan says:

    Republicans say we can trust capitalism and we can put our faith in the honesty of the private sector to do the right thing and to have integrity. Meanwhile, that same capitalistic mentality of the honor system continues to bilk Medicare by billions of tax dollars with little or no oversight. Reminds me of how Republicans continue to want to protect Wall Street in the aftermath of The Great Bush/Cheney Recession of 2008. The worst recession since the Crash of 1929 followed by The Great Depression. Yeah…we can trust private enterprise just like we can trust Republicans…NOT! Along comes the Affordable Care Act to turn on the kitchen light as we watch the Republican cockroaches scatter to find darkness to hide. Scumbags!

  2. Russell says:

    We operate a home health agency with around 1,500-2000 patients on any given day. Although the Face-to-face (F2F) is very burdonsome, we have found ways to help our physicians navigate through the paperwork. As in anything, change is usually not welcomed with open arms, but our physicians continue to adapt. The main challenge we face with our F2F forms is the promptness of their return and having to hound our physicians to sign the paperwork their staff can fill out. As mentioned in the article, the physicians are not being paid for this form as they are with our “Plans of Care”, to which they can bill Medicare for approx. $50 depending on their geographic location. We need to pay them for this documentation.

  3. VB says:

    It’s absolutely ridiculous that Home Health Agencies will have payment taken back for medically necessary because the doctor did not “word” the narrative for reason for the patient’s homebound status or need for skilled care. If the physician was not specific enough, Medicare will take back the entire payment from the home health agency, which cared for the patient (usually) for 60 days. The physician is not penalized for “insufficient” documentation, only the home health agency. The RAC (Recovery Audit Program) is paid based on how much money is recouped from the home healthcare agency. So if the RAC auditor decides the sentences written by the physician is “insufficient” they are paid. Yes, the RAC auditor is paid. Forget about if the patient actually needed the care or was homebound. Basically, home health care agencies are being tremendously hurt financially because of a documentation of a few lines on a one piece of paper that is some information documented throughout the chart.

    Keep in mind, that every progress note completed by the caregiver (nurse, therapist, home health aide) documents the patient was homebound and is SIGNED by the patient. In addition, the physician writes the medical order before care begins for home health care and certifies the need for home care, by signing a home health certification and plan of Care after being evaluated by a licensed caregiver. The Plan of care “certifies” that the patient is HOMEBOUND, receiving and requires skilled home health care, services are under the care of a doctor. It also lists every diagnosis and medicine of the patient. So, the one page Face to Face documentation is another piece of redundant paper that can cost a home health care agency thousands of dollars without affecting the physician and making CMS look like they found payments that shouldn’t have been paid to the home care agency.
    Physicians were not properly trained by CMS or Medicare or any agencies. Home Health Care Agencies were also not sufficiently trained either, nor trained to teach the physician what or how to write the narrative.
    This is a way to take money from home health agencies and make the government look like they are finding all types of fraud because a few sentences were not written properly. Auditors and Medicare Intermediaries should review the entire Medicare chart to determine if the patient was homebound and then train physician on how to write the redundant Face to Face document. They should also have implemented this requirement in stages or phase, like the PECOS enrollment. For PECOS, physicians were required to enroll by October of 2009. Physicians not enrolled would not be paid by Medicare and because it cost physicians money, the PECOS enrollment requirement was postponed until January 2014. YES 5 years. The FTF (Face-To-Face) requirement happened in much less time, probably because physicians do not have a financial impact.

    The governing bodies (CMS, Medicare) indicate these were improper payment based on a technicality and based on the wording from a physician who is not affected and could care less if the agency is paid or not. Ridiculous.

  4. Facts:
    Medicare has always required physician certification from doctors for every case. That is nothing new.

    What is new is that the doctor has to fill out, in his/her own words, three paragraphs of narrative explaining why they ordered home health and that they are qualified to order home health. This is the new Face-to-Face documentation made up by CMS.

    It is problematic because CMS is asking doctors to document things the way home health agencies have to document. Technically CMS said almost nothing to doctors and they let home health agencies deliver the bad news. Doctors are not accustomed to or agreeable to this type of documentation. For instance, when asked to explain why an 80-year-old patient is homebound, a surgeon thinks it’s okay to write “total knee replacement.” While this would make sense to any thinking human being, CMS’s commission-based, contracted auditors will read that and reject an entire $4,000 rehab bill without even reading the rest of the documentation. Their argument is that TKR in an octagenarian doesn’t necessarily mean the patient shouldn’t walk on it, so the doctor has to write more. Home health nurses have been put through the ringer like this for decades, but doctors are used to having to put up with that level of ridiculousness.

    Doctors are paid $50 to $100 for certifying home health plans of care. There are Medicare billing codes specifically for that service.

    I’m not usually a conspiracy theorist, but it’s hard to imagine why making doctors fill out this paperwork, this way is good for patients. Patients are being denied medically necessary services due to CMS games. If they want to restrict the benefit to save money, CMS should just do that instead of annoying doctors, vilainizing home health agencies, and making seniors think they have benefits that they may not be able to access.

    In the past, the home health nurse could examine the patient and paperwork, write up the orders the way CMS would want to see them, give those orders to the doctor to review their correctness, and then the doctor would sign that. The new Face-to-Face documentation rules force doctors to write letters to CMS according to a documentation standard that makes zero sense to them, or any thinking person for that matter. Doctors should not be required to learn the peculiar documentation requirements of every subspeciality they are forced to supervise under Medicare’s cheap rule. For that matter, that would be an undue burden on them, since those documentation requirements often have much more to do with peculiar, bureaucratic nonsense, and nothing to do with medicine. The requirement that the certifying doctor should have an actual doctor-patient relationship is a good home health documentation requirement. The narrative rules that CMS made up are the true fraud.