Face-to-face encounter documentation remains a pain point for home health providers.
It makes sense why, too. The rules and regulations around it are often inconsistent, but there are also ways for providers to fight back against claim denials.
Face-to-face documentation is already one of the top reasons for those claim denials in Medicare and Medicaid, and also, the regulatory guidelines have recently changed – a further reason why providers need to hone in on best practices.
There are multiple aspects of the process that have somewhat fraught guidelines, C3 Advisors President Sharon Harder said on a webinar hosted by WellSky last week.
“So in essence, what we have – especially for home health – is sort of a hodgepodge of additions to the original rule, which has muddied the water, to say the very least,” Harder said. “Consequently, navigating the face-to-face guidance can be a challenge, even for those of us who do it for a living day in and day out.”
For instance, Chapter 6 of the Program Integrity Manual states that without a valid encounter and certification at the start of care, there can be no following reimbursement for services for any certification period in a series.
But that has never been technically written into the regulations, Harder said.
The first time it did come up was in 2013 when the U.S. Centers for Medicare & Medicaid Services (CMS) published a list of FAQs, which did say that CMS has intended that to be the case. But it was never written into the regulations specifically, Harder said. And also, that FAQ document is no longer available.
What further muddies the water is that home health providers are now obviously working with a variety of payers. Some even have more business these days with Medicare Advantage (MA) plans than they do with traditional, fee-for-service Medicare.
But MA does not have the same rules for face-to-face encounters.
“We know that we have to have face to face Medicaid – all Medicaid plans require face to face,” Harder said. “Medicare Advantage, on the other hand, has the option to require it or not. Some of them do and some of them don’t. So you have to be aware of those rules with respect to the Medicare Advantage plans that you were work with.”
Providers are also supposed to match the primary diagnosis of the face-to-face encounter with the subsequent plan of care.
However – especially for providers working under the Review Choice Demonstration (RCD) – this is not always a valid reason for a denial, according to Harder.
For instance, there may be multiple comorbidities or chronic conditions that are working together to make up a complex patient, and therefore, the claim should not be denied. Providers can then argue that in their appeal.
There are also discrepancies regarding timing when it comes to face-to-face documentation. Dates are supposed to be included in the body of the certification language theoretically, but back in 2015, questions rose on how EMRs would factor into that.
“Consequently, CMS has changed the language a little bit in Chapter 7, which once again, can be a point of argument for us.”
Who can certify home health care – and how they can certify it – has also changed during the public health emergency.
At the same time, some of that is also not hardwired into the regulations for home health care, adding further confusion for providers.
“Interestingly enough, on the hospice side, CMS wrote into the permanent regulations that during a public health emergency, hospice face to face could be conducted through telehealth,” Harder said. “They did not do it for home health. So the only time that we can have telehealth – except for when the the 1135 Waiver is in effect – is when we have an originating site that is on that list.”
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