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Medicare’s New Face-to-Face Rules Must be Implemented

October 15, 2015 by  
Filed under Home Health & Hospice

Medicare's new face-to-face rules must be implemented and followed.(October 15, 2015): Many agencies have expressed relief that, effective January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) mostly eliminated the narrative component of the face-to-face (F2F) requirement.[1] As most agencies across the country readily understand, the narrative rule was hopelessly vague and not interpreted or applied consistently by the Medicare contractors. Unfortunately, the new version of the face-to-face regulation may not afford agencies the relief from improper claim denials that they have been hoping for.  Medicare’s new face-to-face rules must be properly implemented and documented. As a recap, the elements of the new face-to-face requirement are as follows:

 

  • The encounter must be performed by an “allowed” type of provider (e.g. certifying physician, physician who cared for the patient in an acute / post-acute setting, physician assistant, nurse practitioner, etc.).

  • The encounter must still be performed 90 days before the start of care (SOC) or 30 days after SOC. In a case where the physician orders home health for a new condition that was not apparent during an encounter performed 90 days prior to SOC, a new encounter must be performed to address that condition within 30 days after SOC.

  • The records of the certifying physician or the physician who cared for the patient in an acute or post-acute setting must corroborate the patient’s homebound status and need for intermittent skilled services. The records must also validate that the encounter occurred within the appropriate timeframe, was performed by an “allowed” type of provider, and was related to the primary reason why the patient was admitted to home health.

  • An agency may provide information to the physician for incorporation into his / her medical records that substantiates a patient’s homebound status and skilled need. However, the physician must sign off on this information, incorporate it into his / her medical records, and the information must be consistent with and supported by the entries in the physician’s own records.

  • Physicians are required to provide the supporting documentation of the face-to-face encounter to the home health agency and / or CMS upon request.

As many agencies already understand, however, Medicare’s new face-to-face rules may end up being just as problematic as the older version of the rules. Ultimately, the face-to-face requirement is a significant burden on agencies because it places the validity of the agency’s claim and its reimbursement in the hands of a separate, independent physician. And as most agencies will readily attest, it is oftentimes difficult enough to persuade physicians to timely date and sign orders, must less write (or re-write, as the case may be) medical record entries to confirm the eligibility of a patient for home health services. Although CMS has stated that physicians who demonstrate a pattern of refusing to comply with this new rule may be subject to certain consequences, those penalties – such as denial of the claim submitted by the physician to bill for the face-to-face encounter or the initiation of a physician-specific probe review by a Medicare contractor – are not nearly as severe as those potentially faced by the home health agency, particularly in cases involving payment suspensions or extrapolated overpayments.

In addition, although CMS has provided some examples of face-to-face records that it would considerable acceptable, the new “supporting documentation” component of the rule is just as vague as the narrative requirement. This new standard may be subject to just as much inconsistent interpretation as the old rule.

Experience has shown that the Medicare contractors are willing to take advantage of the vague nature of the face-to-face requirement in order to deny otherwise appropriate claims for home health services. Home health agencies must therefore be proactive in working to achieve effective compliance with the face-to-face rule. Here are some tips for agencies that may be struggling with the implementation of this new rule:

  • Conduct an inservice with your referral sources regarding this new requirement. This will be a great opportunity provide physicians with valuable resources – such as a “cheat sheet” that summarizes the major elements of the rule and examples of correct face-to-face documentation.

  • Conduct periodic re-training with physicians as appropriate. Don’t expect that they will remember all of the different parts of this potentially complicated rule after just one inservice.

  • The face-to-face documentation must be complete before you bill the end of episode (EOE) claim to Medicare. So don’t be afraid to ask physicians to add late entries to their documentation in order to substantiate homebound status and skilled need, if appropriate, before you bill. Remember that any such amendments / corrections must comply with applicable Medicare requirements for late entries. Excessive or inappropriate late entries may subject physicians to increased scrutiny, audits, or investigations.

  • Obtain face-to-face documentation from physicians before you bill every applicable final claim to Medicare. Do not simply hope that the physicians are documenting the face-to-face encounters appropriately. In addition, agencies may find that physician documentation is lost or unavailable if they are subject to a post-payment audit several years after the claims were initially paid.

  • Consider no longer accepting referrals from physicians who refuse to document face-to-face encounters correctly.

These basic steps should help your agency to achieve and maintain ongoing compliance with the new version of the face-to-face regulation. Once again, it is absolutely imperative that you take proactive measures to ensure that your claims will not be subject to denial simply because a referring physician may not have appropriately documented a face-to-face encounter.

Liles Parker attorneys have extensive experience assisting agencies across the country with compliance programs and government audits / investigations. Contact Adam Bird for a free consultation if you have a question or concern about any laws, regulations, or policies regarding home health services.

Bird,Adam-WebAdam Bird is a health law attorney with the firm, Liles Parker, Attorneys & Counselors at Law.  Liles Parker has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Our attorneys represent home health agencies, hospices and other health care professionals around the country in connection with government audits of Medicaid and Medicare claims, licensure matters and transactional projects.  Need assistance?  For a free consultation, please call: 1 (800) 475-1906.

 

[1] The narrative rule still applies in cases where a patient is referred to home health for skilled management and evaluation of his / her care plan.

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