With the new year comes a new and potentially onerous Center for Medicare and Medicaid Services (CMS) regulation about home care. Effective Jan. 1, CMS-1510-F governing payment for home services will have a far-reaching impact on Medicare patients and their providers.
Under the new regulation, when ordering home-health services, a physician or qualified non-physician practitioner (NPP) must certify that there’s been a documented face-to-face encounter with a patient about the primary reason the patient needs home care. This must be done within 90 days before the start of care or 30 days afterward. Home-health agency staff, including liaisons, cannot perform this certification because of potential financial conflicts of interest.
This new requirement is part of The Patient Protection and Affordable Care Act. The stated goal? To increase physician involvement in patient care and improve outcomes.
I’m old enough to remember house calls, and while I know they won’t return, I still believe physician involvement – contact with patients – should be at the very foundation of health-care delivery. Apparently lawmakers, looking for (more) ways to cut costs and increase accountability, agree but found that’s not always the case. So, we now have this new regulation that micro-manages providers.
How It Works.
Only a qualified nurse-midwife, physician assistant, nurse practitioner or clinical nurse specialist with physician supervision can conduct the face-to-face encounter – as long as they don’t work for a home-health agency.
• Impact on hospitals. Case managers must start considering changes to their workflow. For starters: Who, as part of the discharge process, will perform the face-to-face encounter? What documentation certifying that encounter will be transmitted to home-health agencies? Remember, if there’s no certification, there’s no reimbursement so agencies will be looking for documentation. Otherwise, they may not take patients; patients may linger in the hospital causing throughput problems; or patients may instead be sent to less appropriate alternatives like a SNF or sent home without services, only to be readmitted.
• Impact on home-health agencies. Home-care providers are still responsible for ensuring that there is a physician-signed plan of care, physician-signed order and physician-signed certification in addition to the new certification of a face-to-face encounter.
That certification should include when the encounter took place, the clinical findings of the encounter and how those findings support medical necessity for home-health services.
Critics of the new requirement have warned that some home-health agencies may go out of business, because there will be less business: Patients are homebound and getting to a physician’s office, or even a nearby telehealth center if you can find one, will cause an undue hardship, especially in rural areas. Additionally, getting an appointment after discharge is already a problem for many and will become more difficult. So, the argument goes, patients will go without needed home care, likely causing more readmissions.
The unintended impact of CMS-1510-F then will be that an already bad readmission problem with Medicare patients gets worse, especially at the beginning of 2011 as clinicians incorporate this face-to-face requirement into their workflow.
My suggestion: Make sure you’re tracking readmissions from home care without services. If you start trending upward, it may be a sign that you need to improve how you’re handling face-to-face certification.
Jackie Birmingham, RN, MS, is vice president, emeritus, of clinical leadership at Curaspan Health Group.