On May 20th, the Home Care Alliance of MA, along with several member agencies, physicians and a representative from the MA Medical Society had the opportunity to speak to a number of officials at CMS regarding problems with the face to face rule. Among those on the call from CMS were: Laurence Wilson, Director, Chronic Care Policy Group; Carol Blackford, Deputy Director, Chronic Care Policy Group and Randy Throndset, Director, Division of Home Health and Hospice.
Below is the summary of the meeting and our suggested fixes as sent to the CMS officials in a follow-up email. Thank you to members Judy Flynn and Dr Mark Yurkofsky, Partners Health Care at Home; Robin Seidman, Metrowest Home Care & Hospice; Dr Richard Lopez and Keren Diamond, Atrius Health/VNA Care Network/VNAB, Jeanne Ryan, VNA & Hospice of Cooley Dickinson, and Alex Calcagno, Mass Medical Society for participating and making such a strong presentation.
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Mr. Wilson, Ms. Blackford, Mr. Throndset, Ms. Harrison, Ms. Loeffler, and Mr. Heath:
On behalf of all the participants, thank you for the time spent on Tuesday discussing the face to face rule and its implication for quality care delivery and home health agency/physician relations. Our concerns (summarized) have been:
- the degree to which the content of the narrative supporting homebound and skilled care has become the defacto indicator of compliance with the law regarding the encounter (especially as these qualifying criteria are also documented by the physician on the 485).
- the inconsistency in medical reviews as to what constitutes a sufficient documentation standard, rendering any degree of education almost moot. This is evidenced by the fact that denial rates are going up not down despite the large degree of education agencies are doing. Also evidenced by the attached forms, which were referenced in our handout and reviewed by Partners Health Care at Home on the call.
- confusion and inconsistency in medical reviews around the use of check boxes. Specifically referenced was this Question 24 from CMS Q&A link http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/QandAsFull-5-4-12.pdf
- the huge disconnect between CMS’ impression that your current requirements – according to our letter from Ms Tavenner “allow for the greatest flexibility.” Yet in practice the regulation in its requirements — especially the requirement that all documentation supporting the face to face requirement must be in a single place and “signed, dated and labeled as such” — is anything but flexible.
Our suggestion for immediate action is to stop holding agencies fiscally accountable for inadequate documentation by physicians of the F2F encounter until such time as:
- the CMS contractors have more consistent and clear standards for requirements and are reeducated to follow the guidance provided by CMS in the Q&A document.
- CMS provides clear instructions to physicians regarding the narrative requirements for documentation of the F2F encounter.
We further urge that CMS halt extra face to face related reviews and probes, halt recoupments for denials under review to date, and convene an independent panel to look at inconsistency of denials to date, not only around narratives, but use of check boxes
We also request that CMS clarify: 1) with MACs, the use of checkboxes generated and 2) with health plans and providers, that the face to face requirement does not have to be met for beneficiaries enrolled in a Medicare Advantage plan.
We look forward to hearing from you on these issues as soon as possible.
Our suggestions for a permanent fix, which may or may not be mutually exclusive and may require a rewrite to the regulation:
- Rewrite the regulation to establish that physicians/hospitals should be mandated to maintain the F2F documentation in their medical records, not in the home care record. Home health agencies should only be responsible for recording the date of the physician encounter on our Plans of Care (retired 485), where all the other eligibility requirements exist.
- Drastically rethink the compliance instructions regarding post hospital discharges. CMS has continued to state that they are providing “greatest flexibility to physicians and home care agencies by not requiring a specific form;” however the content of physicians’ clinical notes and discharge summaries can not satisfy the face to face encounter requirements because it is not practical to reconfigure an Entire EHR to re-label and configure a discharge summary to satisfy a “home care regulation.” Clearly, any patient being referred to home health care from a hospital setting will have had a face-to-face encounter with a physician during their hospital stay. We strongly urge CMS to waive the F2F documentation requirement for patients who have had an inpatient hospital stay within 15 days before their home health admission.
- In lieu of waiving the extensive documentation requirement for patients entering home health immediately following a hospital stay, the regulation should be written to reduce duplicate documentation for the common situation in which the physician who performs the face to face encounter IS NOT the physician following the patient in the community. We are happy to work with CMS on a process that reflects this scenario.
- Engage a focus group of practicing physicians to work with CMS to rethink and revise the MLN Matters SE1405 and the examples contained therein. An example such as that on page 11 (which has no less than 5 references to the patient’s ability to walk/ambulate) presents an unrealistic standard of documentation. Consider that a physician documenting an “open wound” and “a broken femur in a 92 year old,” believes based on all previous medical training that, implicit in the diagnosis, patient wound and age, are conditions that any clinical reviewer would recognize require skilled care and restrict the patient’s ability to leave the home.
All of us on the call appreciate the time, the attention and most of all the commitment to work to make this new requirement work to enhance and not impede care.
I look forward to hearing back from you.
Pat Kelleher
Home Care Alliance of MA
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