HH Face-to-Face Encounter NO postponement

Subject: Home Health Face-to-Face Encounter Requirement

Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services.

Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner  working with the physician, has seen the patient.  The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care.  Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.

Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient’s 180th-day recertification, and each subsequent recertification.  The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period.  The provision applies to recertifications on and after January 1, 2011.

On December 23, 2010, due to concerns that some providers needed additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, CMS announced that it will expect full compliance with the requirements, beginning with the second quarter of CY2011.  

Throughout the first quarter of 2011, CMS has continued outreach efforts to educate providers, physicians, and other stakeholders affected by these new requirements.  CMS has posted guidance materials including a MLN Matters article, questions and answers documents,  training slides, and  manual instructions which are available via  CMS’ Home Health  Agency Center and Hospice webpages.  CMS’ Office of External Affairs and Regional Offices contacted state and local associations for physicians and home health agencies and advocacy groups to ensure awareness about the face-to-face encounter laws, and to distribute the educational materials. 

CMS will continue to address industry questions concerning the new requirements, and will update information on our Web site at http://www.cms.gov/center/hha.asp and http://www.cms.gov/center/hospice.asp.

How should Medicare payments change in 2012?

Report to the Congress: Medicare Payment Policy | March 2011

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SUMMARY OF RECOMMENDATIONS

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8-1 The Secretary, with the Office of Inspector General, should conduct medical review activities in counties that have aberrant home health utilization. The Secretary should implement the new authorities to suspend payment and the enrollment of new providers if they indicate significant fraud.

COMMISSIONER VOTES: YES 16 • NO 0 • NOT VOTING 0 • ABSENT 1

IMPLICATIONS

Spending

The Congressional Budget Office has already scored savings from the PPACA provision, so its baseline assumes savings for the new authorities. Implementing this authority for home health care would lower home health spending if fraud were discovered. CMS and the Office of Inspector General would incur some administrative expenses to conduct these activities.

Beneficiary and provider

Appropriately targeted reviews would not significantly affect beneficiary access to care or provider willingness to serve beneficiaries.

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8-2 The Congress should direct the Secretary to begin a two-year rebasing of home health rates in 2013 and eliminate the market basket update for 2012.

COMMISSIONER VOTES: YES 16 • NO 0 • NOT VOTING 0 • ABSENT 1

IMPLICATIONS

Spending

This recommendation would reduce Medicare spending $250 million to $750 million in 2012 and $5 billion to $10 billion over 5 years.

Beneficiary and provider

Some reduction in provider supply is likely, particularly in areas that have experienced rapid growth in the number of providers. Access to appropriate care is likely to remain adequate, even if the supply of agencies declines.

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8-3 The Secretary should revise the home health case-mix system to rely on patient characteristics to set payment for therapy and nontherapy services and should no longer use the number of therapy visits as a payment factor.

COMMISSIONER VOTES: YES 16 • NO 0 • NOT VOTING 0 • ABSENT 1

IMPLICATIONS

Spending

The approaches could be implemented in a budgetneutral manner and should not have an overall impact on spending.

Beneficiary and provider

This recommendation would increase payments for hospital-based agencies, rural agencies, and small agencies. Patients who need therapy may see some decline in access, but these services would be available on an outpatient basis after the home health episode ended.

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8-4 The Congress should direct the Secretary to establish a per episode copay for home health episodes that are not preceded by hospitalization or post-acute care use.

COMMISSIONER VOTES: YES 13 • NO 1 • NOT VOTING 2 • ABSENT

IMPLICATIONS

Spending

A copay of $150 per episode (excluding low-use and post-hospital episodes) would reduce Medicare spending $250 million to $750 million in 2012 and $1 billion to 5 billion over five years. Expenditures for services would decrease because some beneficiaries

who would otherwise use home health services might decline them. Since many of these services are funded by Part B, decreases in spending growth would reduce Part B premiums.

Beneficiary and provider

Some beneficiaries might seek services through outpatient or ambulatory care, for which Medicare already has cost-sharing requirements. Some beneficiaries who need relatively few services would have lower cost sharing if they substituted ambulatory care for home health care.

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Recommendation 3B-2A from the Commission’s March 2010 report

The Congress should direct the Secretary to expeditiously modify the home health payment system to protect beneficiaries from stinting or lower quality of care in response to rebasing. The approaches should include risk corridors and blended payments that mix prospective payment with elements of cost-based reimbursement.

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