CMS' Home Health Face-to-Face Rule Too Burdensome, Says AAFP

Academy, Other Groups Seek to Delay April 1 Deadline

March 16, 2011 12:15 am News Staff

The AAFP and a dozen other national health organizations are calling on CMS to delay the April 1 implementation date for the agency's face-to-face encounter rule that applies to patients needing home health care. Enforcement of the rule should be delayed until no earlier than July 1, say the groups.

The rule stems from CMS' interpretation of section 6407 of the Patient Protection and Affordable Care Act and states that a physician who certifies a patient as eligible for Medicare home health services must see the patient in a face-to-face encounter within 90 days before the start of home health care or within 30 days after the start of care.

The provision went into effect on Jan. 1, but CMS agreed in December of last year to delay enforcement until April.

In a March 12 letter(5 page PDF) to CMS Deputy Administrator and Center for Medicare Director Jonathan Blum, the organizations -- including, in addition to the AAFP, the AMA, the American Academy of Home Care Physicians, the American College of Physicians and the National Association for Home Care & Hospice, or NAHC -- now are asking CMS to further extend the rule enforcement date to no earlier than July 1.

"Despite the extraordinary efforts to achieve a level of understanding and an intention to comply, all of the undersigned parties are very concerned that patients will lose access to vitally needed care," says the letter.

FPM Blog Discusses Face-to-Face Rule

Details on the new home health face-to-face requirements called for by the Patient Protection and Affordable Care Act are available in a March 11 posting to Family Practice Management's "Getting Paid" blog.

According to that posting, the law allows the face-to-face requirement to be satisfied if a non-physician practitioner, or NPP, sees a patient seeking home health care services when the NPP is working for or in collaboration with the physician. Such a face-to-face encounter would need to occur within 90 days before the start of home health care or within 30 days after the start of care.

The law also allows a physician who attends a patient but does not follow that patient in the community, such as a hospitalist, to certify the need for home health care based on that physician's face-to-face contact with the patient in the hospital. That physician then would "hand off" the patient to his or her community-based physician to review and sign off on the plan of care.

Provisions also are in place to allow the use of telehealth technology to fulfill the face-to-face obligations in rural areas.

Among numerous reasons necessitating the extension of the transition period, say the groups, are the results of a comprehensive NAHC survey that documented

  • confusion regarding the paperwork obligations for physicians,
  • still-evolving policy interpretations and guidance, and
  • the need for more time to ensure that physicians and non-physician providers understand the requirements of the face-to-face rule.

The letter specifically points to physician angst with an ever-growing documentation burden demanded by CMS and other agencies and notes that "physicians have voiced concerns that burdensome documentation procedures are often barriers to achieving compliance."

Pursuant to an executive order issued by President Obama on Jan. 18 that calls for government agencies to "consider regulatory approaches that reduce burdens and maintain flexibility," the organizations suggest that "documentation
requirements for the face-to-face encounter can be significantly streamlined."

In particular, the letter takes issue with CMS' interpretive guidance that requires physicians to provide a "narrative" as to why a patient's clinical findings specifically support Medicare coverage.

"Many physicians see this added documentation component as unnecessary, duplicative and unduly burdensome," says the letter.

The letter offers several recommendations -- compiled from the NAHC survey -- that would simplify physicians' administrative burden. Those possible solutions include

  • allowing the use of check-off boxes, as is done in the current form;
  • eliminating the narrative and instead requiring documentation that the encounter occurred;
  • permitting home health agencies to assist physicians with the documentation; and
  • allowing existing supporting documentation to be attached.

Misinformation also has been a barrier, says the letter. In direct communications with CMS as recently as last month, the groups note, "physician and hospitals groups indicated that policy clarifications, modifications and misinterpretations in the field mean that educational efforts must first dismiss incorrect information before accurate guidance can be absorbed."

According to the organizations, "The extension sought will allow for resolution of any interpretive issues, comprehensive awareness actions and full 'dry run" testing" to ensure compliance.

Finally, to address specific concerns about patient access to care, the organizations ask CMS to monitor -- in real time -- beneficiary access to home health care by requiring home health agencies to report to the CMS' fiscal intermediary any episode where patient home health services are denied because of the lack of a face-to-face visit.