Update on F2F
20 years ago this month, when I decided I had done my dues as a night shift nurse, had a new daughter that would need daycare and wanted to see the light of day on a regular basis, I took my first real position as a home health nurse. I started learning the rules which were pretty simple at the time. We did skilled care, we tried to prevent hospitalizations and we kept some people on service a long time as long as they were homebound. We had 485s, but not OASIS or HIPPA, and agencies were paid per visit. I lived in a large rural county and drove a lot of miles to see my patients. There was only one other agency in the county so we didn’t worry much about competition. We were usually glad to find someone was no longer homebound so we could discharge and free up the schedule a bit.
One day the state surveyor came. She wasn’t happy with our director and told her some things to take care of. A few weeks later she was back and telling us she was closing us down. Apparently the Director had not taken her seriously. We went to the CEO of the hospital. He negotiated, fired the director and brought in consultants to teach us the real rules and we went through the first real intensive training for home health I ever saw.
The Homebound rule was made abundantly clear at that time and, of course, we often debated the nuances of it. There always were, and will be, the challenge of balancing the real need and the care in those who fall into grey areas. But most honest home health agencies have a pretty clear idea after 20 years what constitutes homebound status. And most honest HHAs will have clinicians document homebound status regularly and discharge patients when they no longer meet the criteria.
Enter 2011 and the new Face to Face requirement, where physicians who have been signing 485s for years suddenly have to be the ones to state why the client is homebound. It is like jumping back 20 years. I put the question on a forum and responses are amazing. These are some of the examples I have seen.
“Just got a F2F form back from a physician and on the homebound status he wrote “N/A” …… unbelievable “
“My favorite so far was “because he’s old” patient was 90+”
“When we first started using the form, one of our physicians wrote under the homebound status: no footprints in the snow…”
If this were the worst of it we could laugh and move on but the sad truth is that the F2F rule which requires the physician actually see a patient and write out a reasonable reason for homecare and homebound status seems to be a final straw for many physcians. But it is also having a huge administrative impact on home health agencies. One responder on the forum wrote,
“Oh My , F-2-F is not going well I am sure with most agencies, We have had to dedicate one employee who spends at least 80% of her time tracking and attempting to get the documentation as well as getting the documentation filled out correctly. CMS has gone overboard on this one.”
A survey done in February 2011 by NAHC yielded a 381 page document of the difficulties HHAs were already encountering.
http://www.nahc.org/Regulatory/home.html#comments
What is supposed to be curbing fraud and abuse is angering physicians who do not want to deal with it. They are not completing the forms; they are threatening or actually dropping home health patients rather than write a short statement validating what they have been signing all these years. Agencies are scrambling to placate them, some committing more of what will be considered fraud by attempting to assist the physician with check box or prewriting the homebound reason.
From a clinical stand point, I don’t really object to the Face to Face rule. I don’t think it is unreasonable to expect a physician to evaluate a patient before or soon after ordering Home Health. I recognize that it can be a logistical burden in some cases. But a good percentage of initial referrals come from a hospitalization or MD appointment. The encounter itself does not seem to be the major issue. I believe that physicians don’t want to be held more accountable for trying to determine the wording for why someone is homebound when they have already signed a statement that they are on the 485.
Should HHAs be deprived payments if a physician doesn’t do their job according to CMS standards? Should they have to add additional administrative hours to educate and police physicians? Should deserving patients lose an important healthcare benefit because their doctor doesn’t want to deal with additional paperwork? Of course not!
But, the sad truth is they will, unless there is a change in the requirements. So what can you do as a new agency to minimize the impact on your company? The best answer seems to be to attempt to have the F2F documentation done prior to your acceptance of the patient. Educate discharge planners and physician offices that this is the requirement and make the appropriate form easy for them to access with appropriate samples. Remember you cannot use check box reasons or complete it for the Physician to sign, neither can the discharge planner. If you can’t get it before you take on the patient, be sure you make it clear that you need it ASAP and keep on it so offices know you follow through. Document every contact until you get what you need. It may mean more time initially but it will become common practice eventually.
Use forms and educational material as part of your marketing. Be sympathetic, but firm with the additional paperwork burden of the physician. It will do you no good to try and get around the regs by doing it wrong so you get the client over someone else. Those companies will end up losing money and having more issues. If CMS is looking for ways to bankrupt agencies they will go after them.
As usual, I would welcome your comments or even just a brief update on how your agency is doing. If you don’t want to receive this newsletter, just reply with unsubscribe as the subject and I will remove you from my contact list. If you are ready for great software to run your agency, let me know.
