On July 7, 2014, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule updating the Home Health Prospective Payment System (“HH PPS”) rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply conversion factor under the Medicare prospective payment system for home health agencies (the “Proposed Rule”). The Proposed Rule also proposes important changes to the face-to-face encounter requirement mandated by the Affordable Care Act.
The current face-to-face regulations, which went into effect April 1, 2011, require the physician responsible for performing the initial certification to document that “the face-to-face encounter, which is related to the primary reason the patient requires home health services, has occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care by including the date of the encounter, and including an explanation of why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services.” 42 C.F.R. §424.22(1)(a)(v) (emphasis added). According to CMS, the “explanation” (or physician narrative) requirement was intended to discourage physicians from relying solely on information provided by home health agencies when making eligibility determinations and other decisions about patient care. However, since its implementation, many stakeholders expressed concern that the narrative requirement would diminish access to home health services. In addition, many home health providers have noted an increase in denials of claims as a result of inadequate narratives. The National Association for Home Care & Hospice recently filed a lawsuit challenging the physician narrative requirement.
In response to these concerns, CMS is proposing to eliminate the narrative requirement. However, it is important to note that the Proposed Rule does not eliminate the face-to-face requirement. The certifying physician would still be required to certify that a face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician (or allowed non-physician practitioner), and to document the date of the encounter as part of the certification of eligibility.
The deadline for comments on the Proposed Rule is September 2, 2014.
SUNSHINE ACT DISPUTE REVIEW PROCESS NOW OPEN
Physicians and teaching hospital representatives can now review and dispute data submitted about them pursuant to the Physician Payments Sunshine Act (the “Sunshine Act”), which requires manufacturers of drugs, medical devices and biologicals that participate in Federal health care programs to report payments or other transfers of value to physicians and teaching hospitals (“applicable manufacturers”).
To review the data, physicians and teaching hospital representatives must first register through CMS’ Enterprise Portal. The dispute and resolution process will end on August 27, 2014. CMS plans to publicly release the data submitted by applicable manufacturers on September 30, 2014.