Tag Archives: Face to Face Encounter

Palmetto GBA expands Probe & Educate initiative

Home health agencies in the 16 states served by Palmetto GBA Medicare Administrative Contractor could see a significant increase in the amount of records reviewed as part of an expanded Probe & Educate initiative.

Some agencies could be required to provide as many as 20-40 records on average instead of the five records requested for previous Probe & Educate reviews, according to Bobby Lolley, Executive Director of the Home Care Association of Florida.

“This review will be extensive, with 20-40 records on average being requested, not just another five records like in previous rounds,” Lolley said in an email to HCAF forum members this week.

Agencies subject to the significantly increased record requests are those which received denials of two or more records reviewed in an earlier round of the Probe & Educate initiative.  Some of those agencies did not receive specific instruction they were expecting from the MAC as part of the process because the Probe & Educate initiative was suspended earlier this year.

Lolley said all agencies in Round 2 can be subject to further review, even those agencies which did not complete Round 1 and receive one-on-one education from the MAC before that round was suspended.

Lolley said Palmetto provided the following  statement to a home health coalition request for clarification about agencies which did not receive one-on-one instruction : “Providers are being progressed if they did not request education on or before their due date. We have a number of providers that missed their deadline to request education, so yes, there is a chance that they have been progressed before they are receiving their education.“

Focus on the F2F

“Mac reviewers will be looking at the claims to ensure that agencies are in compliance with Medicare eligibility and payment requirements,“ said J’non Griffin, owner of Home Health Solutions.  “In Round 1, a substantial number of agencies had problems with the Face-to-Face.”

Additional concerns included a lack of specific orders for therapy and services, omissions and inconsistencies in documentation, but the Face-to-Face was one of the most troublesome areas for agencies, she said.

“Agencies which have not yet received training in the Face-to-Face should make doing so a priority,” J’non said.

J’non will offer an online audio training session titled “Make the Face-to-Face Count” next Thursday, July 13, reviewing valid and invalid F2F items pulled from actual charts, and discussing specific methodologies.  For details, click here.

Hospice agencies may be interested in an online audio training program titled “Improving Hospice Documentation,” presented by HHS Special Projects Director Heather Calhoun on Tuesday, July 11.  For details, click here. 

The 16 states in the Palmetto GBA area include Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, Illinois, Indiana, Ohio, Oklahoma, North Carolina, South Carolina, Tennessee, and Texas.

How home health agencies can meet the pre-claim reviews burden

preclaims-reviews-2
Do you know the two primary risk areas?
Here’s a look at what’s being rejected —
and four things agencies need to do

This article first appeared in the September issue of SOLUTIONS,  a monthly e-newsletter from Home Health Solutions LLC.  If you’d like to receive our free newsletter,  click here to subscribe. 

Six weeks into the first Medicare pre-claim review demonstration in Illinois, the rest of the home health field is watching, hawk-like, to assess the damage and determine industry-wide risk.
Uneasy curiosity hinges on three questions:
What’s being denied? How bad is it? How can agencies insulate themselves?
“As a whole, it’s not going well,” reports J’non Griffin, owner and president of Home Health Solutions LLC.
“One agency has reported getting no non-affirmations — and they say they are uploading 80 to 100 different pages to justify the care for each claim.
“The last figure I saw, though, was about an 80 percent non-affirmation rate overall on the first submission.”
J’non’s assessment is backed up by the National Association of Home Care and Hospice. Bill Dombi, NAHC’s Vice President for Law, has called the pre-claim demonstration in Illinois “a complete mess.”
Agencies have reported individual claims taking up to an hour each to submit.
Some say they are unable to stop and save partially uploaded submissions once the uploading process has begun.
Several agencies say they have repeatedly been told their submissions are illegible. Many say their documents were lost during transmission.
The number of disappearing documents prompted CMS at one point to advise agencies to rely on fax submissions rather than electronic.

What’s ahead?

Currently, NAHC is lobbying Congress to suspend the next rollouts planned in Florida, Texas, Michigan and Massachusetts between now and the first of the year. Florida legislators are taking the lead in the opposition, since Florida is next in line with an Oct. 1 rollout.
But the clock is ticking, and despite overwhelmingly negative reports from home health agencies in Illinois, attempts by lawmakers there to suspend the process, and current efforts of Florida lawmakers to delay the next round, it seems likely for now that the pre-claim demonstration will move forward.
How can agencies prepare?
“To successfully meet the new burden of pre-claim reviews, home health agencies need to get much faster, with fewer documentation errors and oversights, expedited turnarounds, and a thorough understanding of exactly what is expected of them,” J’non says.

(For more information about how agencies can successfully handle PCRs,  be sure to check out the detailed recommendations in J’non’s 4-Point Roadmap for PCR Success,  below. )

Is your agency ready?

Industry experts agree that agencies will almost certainly be forced to hire additional full-time employees to meet the burden of pre-claim reviews. Generally, they estimate that for every 100 to 350 patients an agency serves, an additional one-and-a-half FTEs (one RN and one clerical) could be required.
For many agencies, however, a faster and more cost-effective solution may be to outsource the preparation and submission of pre-claim reviews. Home Health Solutions is now working with agencies needing assistance with PCRs.
“Agencies are discovering, as the requirements placed upon them increase, that it often makes more sense financially to outsource coding, billing and many other services so that they can focus on patient care,” J’non says.

Going it alone?

For agencies choosing to navigate the PCR process on their own, J’non recommends purchasing a helpful tool from Home Health Solutions. Think of the PCR Do-It-Yourself Kit as a $25 compass to point your agency in the right direction to steer through all the necessary paperwork.  A checklist and staff tutorial are included.
To order,  call HHS at 888-418-6970.

Roadmap for PCR success

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J’non also offers the detailed 4-Point Roadmap below to help agencies successfully prepare for the pre-claim review process:

Step 1: EXPEDITE WORK FLOW 
Agencies must streamline their operations, with faster turnaround times for coding, for developing a Plan of Care and getting the physician to sign off on it, and for collecting all documents needed to submit the pre-claim review.
Efficient teamwork will be an essential part of streamlining operations, J’non says.
She recommends agencies:

  • Identify key staffers and their responsibilities, and make certain there is no confusion about who is responsible for each step in the process of completing documents and collecting necessary forms to submit and re-submit claims.
  • Develop a back-up system to avoid delays in the event a key staffer becomes unavailable.
  • Determine who will be responsible for follow-up, and how often.
  • Make certain the person submitting pre-claims has immediate access to all required documentation and billing information.
  • Review the process with the full staff, stressing the need for timeliness and accuracy. Put policies and procedures in writing for easy access to avoid confusion or delays.

 

Step 2. TARGET TWO AREAS MOST LIKELY TO BE REJECTED
Agencies in Illinois are reporting that a high proportion of pre-claim reviews are being rejected on the basis that the patient is not homebound or the care is not shown to be medically necessary.
J’non recommends agencies look closely at their supporting documentation to make certain they have correctly established both patient eligibility and medical necessity.
A few reminders about documenting homebound status:

  • To be considered homebound, the patient must be unable, due to illness or injury, to leave home without special equipment or assistance from another person. Be sure to document WHY the illness or injury requires special equipment or assistance.
  • Document the impact on the patient from any excursion outside the home, the reason for the trip, and the effort required to leave home.
  • Make certain Face-to-Face documentation specifies why the patient is homebound. The physician’s note must specifically address the reason the patient needs home health services.

 

Step 3:  CLEAN UP DOCUMENTATION
Review, review, review. Agencies can’t do too many in-house reviews and self-evaluations as they attempt to shore up compliance risks, limit oversights and reduce errors.
In particular, J’non recommends agencies focus on:

  • Accurate completion of the OASIS, especially in preparation for C-2 revisions which take place Jan. 1. This data collection tool offers numerous areas where clinicians can become confused. The HHS team frequently sees agencies making mistakes as simple as entering dates in the wrong place on this form, erroneously establishing non-compliance.
  • Proper documentation of Face-to-Face Encounters. Make sure the physician has documented the date of the F2F Encounter and provided the reason home care is necessary. A clinical note from the physician will be required, not just a form, and the content of the note must address the reason the patient needs home health care.The signature of a nurse-practicioner or other provider on the F2F will not suffice unless it is a co-signature with the physician. Even if the nurse-practitioner performed the F2F, the certifying physician’s signature and date will be necessary. Review all F2F dates to make certain there are no discrepancies. Mismatched dates are automatically denied.
  • Collect all necessary information before submitting pre-claims
  • Attach the assigned pre-claim number to all final claims and resubmissions.
  • For re-certifications, be aware that the re-certification statement on the projected length of time the patient will need home care will need to be submitted separately from the Plan of Care.
  • Also note that the projected length of care will shorten each time the patient is re-certified unless there is a documented reason showing why that is not the case. In a recent workshop on pre-claims reviews, Palmetto representatives stated that the re-certification statement is expected reflect a shorter duration for each episode of home health care for which the patient is re-certified. The first re-certification projection, for example, might be six months, but the next re-certification projection would be only four months. Be sure to include supporting documentation showing the need for any change in the projected length of stay.

 

Step 4: INVEST IN TRAINING
Agencies will need to shore up training in many areas in order to reduce compliance risks and achieve success in today’s challenging home health market, J’non says. In particular, she recommend OASIS training and F2F review to prepare agencies to better handle pre-claims reviews.
HHS offers online training for both in its online store, with 8 CEUs offered for the OASIS course.
Click here to shop the online store now.

5 Essentials for Your Agency’s F2F Documentation

Can you list the 5 Must-Haves to insulate your home health agency against claims denials based on insufficient Face-to-Face Encounter (F2F) documentation?
Do you know how to incorporate missing elements of the F2F into the medical record?
If you blinked uncomfortably, you’re not alone. These questions are making many home health professionals nervous in the wake of voluminous claims denials after reviews under the Center for Medicare and Medicaid Services “Probe and Educate” Strategy.
Quality Checklist Infographic smaller f2f“It was mind-boggling to  learn early in 2016 that an astonishing 508 of 595 initial claims reviewed under ‘Probe and Educate’ had been denied, ” recalls Home Health Solutions LLC owner and president J’non Griffin.
Over the next few weeks, as reasons for the denials were publicized, it became clear that one of the biggest problem areas for home health agencies consisted of missing, invalid or incomplete documentation for Face-to-Face Encounters (F2Fs) between home health patients and physicians.

F2F REQUIREMENTS

The F2F is mandatory for a patient’s home health certification. It ensures that all orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition. CMS requires that it occur within a specific time frame and address specific information about the patient.
Many agencies relying on forms to capture F2F information discovered that the forms they were previously using omitted details necessary under new CMS requirements.  Agencies also ran into trouble by relying on a physician’s verbal acknowledgement that the F2F had occurred, documenting the encounter and asking the physician to sign.
Some agencies did not understand the distinction between a certifying physician and the primary care physician. Others had not adequately established the patient’s homebound status in records submitted.
Correct procedures for F2F documentation require a brief statement by the certifying physician describing the patient’s clinical condition during the encounter, supporting the patient’s homebound status and the need for skilled services.
While it sounds straightforward, obtaining correct documentation from the physician, complete with required dates and signatures, all in a manner meeting CMS expectations, has proved to be an ongoing challenge for home health agencies.

TRAINING CAN CLEAR THINGS UP

If your agency is struggling with the nuances of F2F requirements, a small investment in training could pay off with major reduction in the risk of claims denials.
Home Health Solutions has just released a recorded training session in which HHS Director of Special Projects and Appeals Heather Calhoun breaks down each component, explaining in detail the five objectives of F2F requirements and specifically how agencies can meet each objective.  During the 90-minute presentation, she outlines three specific ways an agency can incorporate missing elements of the F2F into the medical record, makes clear the homebound status requirements which must be met, and establishes the difference between certifying and primary care physicians.
“You’ll love Heather’s down-to-earth approach to training,” J’non promises. “She has the hands-on experience needed for true peer-to-peer mentoring that goes an extra measure beyond the typical classroom approach.  She delivers all the information you need to understand F2F requirements, and she does it with a practical and engaging style that you’ll appreciate.”

Click here to check out the F2F training program now available  in the HHS Online Store.

 THE 5 ESSENTIALS

The HHS  infographic below provides a quick checklist of the 5 essentials which must be in your agency’s F2F documentation.  Each is explained in detail in the HHS training program.

Quality Checklist Infographic F2F Take 5