Following a recent conference call with industry leaders, it became clear that the home health care industry often fails to take advantage of changes in policy or in the many educational opportunities offered. The latest subject continuing to cause confusion has to do with face-to-face compliance.
In 2011, CMS issued a face-to-face rule that would significantly impede the home health care industry. The combination of the lack of clarity within the rule itself coupled with the industry having little to no control has initiated crippling financial consequences. Increased audits verifying specific compliance with the rule caused denial rates of 80-90% and stifled the growth of many agencies.
Never before had the homecare industry been at the mercy of physicians for the reimbursement of homecare services. CMS was charged with the responsibility of educating physicians on the elements required to complete the face-to-face form. However, the education provided was nearly non-existent and often proved to be ineffective. Most physicians (indeed most professionals) do not care for additional paperwork and this rule required a considerable amount of increased documentation with specificity.
As a result, a number of individual agencies and state and national organizations worked with CMS to change the rule. The initial direction for the 2015 change was confusing for agencies and physicians. QIRT experts’ experience in the field has shown us that most agencies still have not unraveled the requirements of the newest face-to-face rule. Many agencies continue to use the original face-to-face form created 5 years ago, even though the Medicare Administrative Contractors (MACs) have been very clear that the face-to-face form is not what they are looking for.
In 2015, the rule changed. Another five-record review by the MACs in 2015 found compliance with the new rule to be unchanged. In point of fact, the percentage of denials increased. It got worse. Why? Because homecare agencies did not follow the new rule.
Despite the warnings, attempted education, and written instruction by CMS and the MACs, agencies continued to ignore the direction, continued to use the same face-to-face form, ignored the requirement to secure the physician progress note, and more. Today, in the pre-claim review state of Illinois, most of the non-affirmations received from the reviewers are the result of a “lack of information in the physician file.”
Just what is the 2015 Face-to-Face Rule?
The information needed for face-to-face has actually not changed much from the 2011 rule. Agencies still need to show documentation of medical necessity and the two criteria for homebound status. What has changed is that it is now acceptable for the agency to provide the necessary information along with the physician’s information, as a supplement (not replacement) to his/her progress note.
So…it is actually fairly simple. If the agency provides specific items, such as OASIS responses related to skilled need and homebound status (M1800s), therapy evaluations, a medical update written by agency staff, etc., CMS will allow these items to be added to the physician progress note in response to a medical review request, including pre-claim reviews. It is important to understand that the agency documentation supplied must include the physician signature indicating he/she has reviewed and agrees with the supplemental assessment information.
With the 2015 rule, agencies now have the opportunity to support the information on the physician progress note with agency information. Why are agencies not doing this? Hopefully the simple steps outlined above will encourage agencies to review current practices and begin to provide the necessary information, resulting less denials and more accurate and timely reimbursement.
VP Program Development