The Home Health Face to Face Requirement: Will Physician Concerns Over Referrals Become a Reality?

CMS, in an effort to reduce fraud, abuse and waste, beefed up its certification requirements for several health care settings that remain high on the list for improper payments. The face to face requirement is one of those vehicles for change affecting home health agencies, as established by the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148). After a short postponement earlier this year, the requirement is in full swing – the question now becomes, how is it working?  

Many home health agencies pause at the answer. The  regulations require that the face-to-face encounter be performed by the certifying physician or by a nurse practitioner, a clinical nurse specialist who is working in collaboration with the physician or a physician assistant under the supervision of the physician. The documentation of the face-to face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled, dated and signed by the certifying physician. When the face-to-face encounter is performed by a non-physician, he or she must document the clinical findings of the face-to-face encounter and communicate those findings to the certifying physician.

The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care. If the face-to-face encounter occurred within 90 days of the start of care, but was not related to the primary reason that the patient requires home health services, or if the patient has not seen the certifying practitioner within 90 days of the start of the episode of home health care, the practitioner must have a face-to-face encounter with the patient within 30 days of the start of the home health care.

Recertification of the need for home health care must be provided at least every 60 days, with a preference for the recertification to occur at the time that the plan of care is revised.  The recertification must be signed and dated by the physician who reviewed the plan of care. According to CMS, recertification does not require face-to-face.

The face to face requirement has caused much concern between those involved. Pointing to a recent physician poll on the face to face requirement, Barbara Woolley of the National Association for Home Care and Hospice comments in a press release  that:

“The rule of concern requires that Medicare home health care patients have a face-to-face encounter with a physician at the start of care. While the survey indicates that most physicians approve of the encounter requirement, they think that the extensive documentation requirements that are part of the rule are an unnecessary barrier to care. Under the rule, physicians must not only document that the encounter occurred, they must provide an unprecedented detailed narrative describing why the patient meets complex Medicare coverage standards. These extensive documentation requirements are in stark contrast with the simple lab test documentation proposal that Medicare recently rescinded because of concerns on its impact on care.”

Recently, NAHC sponsored a study on physician involvement in home health care. The vast majority – 93% of Physicians surveyed disapprove of the new documentation/certification requirements for home health, say it is a lot more burdensome and want it simplified. Most physicians surveyed believe that fewer patients will be referred to home health as a result of the new rules, and that there will be significant negative health consequences to patients as a result. The study also found that most physicians surveyed favor reforms that would allow existing doctor orders to satisfy the certification requirements for home health, and do away with the written narrative.

CMS does a small bit to address these concerns by amending existing Medicare regulations in its Proposed rule for 2012. The proposed rule would create additional flexibility in meeting the home health face-to-face encounter and certification requirements. What this means is that, for patients who are admitted to home health upon their discharge from a hospital or post-acute care setting, the proposed rule would allow the attending physician to inform the certifying physician about his or her encounter with the patient to satisfy the face-to-face encounter requirement.

 CMS believes that this policy change would encourage more collaborative communication between the patient’s physicians and improve the overall quality of care received by Medicare beneficiaries.  Although the rule was intended to improve phyisician involvement, many wonder if it will result in fewer patient referrals. And if they aren’t going into home health care, where will these patients seek the treatment they require?