Documenting face-to-face encounters remains a pain point for home care providers.
It makes sense why, too. The rules and regulations surrounding it are often inconsistent, but there are also ways for providers to combat claim denials.
Face-to-face documentation is already a top reason for these claim denials in Medicare and Medicaid, and also, regulatory guidelines have recently changed – yet another reason providers need to focus on best practices.
There are several aspects of the process that have somewhat heavy-handed guidelines, C3 Advisors president Sharon Harder said during a webinar hosted by WellSky last week.
“So in essence what we have — especially for home health — is kind of a hodgepodge of additions to the original rule, which has muddied the waters, to say the least,” Harder said. . “Therefore, navigating face-to-face counseling can be a challenge, even for those of us who do it on a daily basis.”
For example, Chapter 6 of the Program Integrity Manual states that without a valid encounter and certification at the start of care, there can be no subsequent reimbursement for services for any certification period in a series.
But that was never technically written into the regulations, Harder said.
The first time this surfaced was in 2013 when the US Centers for Medicare & Medicaid Services (CMS) published a list of FAQs, which indicated that CMS intended this to be the case. But that was never specifically written into the rules, Harder said. Also, this FAQ document is no longer available.
What muddies the water even more is that home care providers are now obviously working with a variety of payers. Some even have more business these days with Medicare Advantage (MA) plans than traditional paid health insurance.
But MA does not have the same rules for face-to-face meetings.
“We know 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 of requiring it or not. Some of them do and some don’t. So you should be aware of these rules with respect to the Medicare Advantage plans you were working with. .
Providers are also expected to match the primary diagnosis from the face-to-face encounter with the subsequent care plan.
However — especially for providers working under exam choice demonstration (RCD) — that’s not always a valid reason for a denial, according to Harder.
For example, there may be multiple comorbidities or chronic conditions that work together to make up a complex patient, and therefore the claim should not be denied. Suppliers can then argue this in their appeal.
There are also discrepancies regarding timing when it comes to face-to-face documentation. The dates are theoretically supposed to be included in the body of the certification language, but in 2015 questions arose about how the EMRs would take them into account.
“As a result, CMS changed the language of Chapter 7 a bit, which again can be an 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 this is also not hardwired into home health care regulation, adding to the confusion for providers.
“Interestingly, on the palliative care side, CMS wrote in the standing bylaws that during a public health emergency, face-to-face palliative care could be conducted via telehealth,” Harder said. “They didn’t do it for home health. So the only time we can have telehealth – except when waiver 1135 is in effect – is when we have an originating site that is on this list.