Congress Takes Up Face-to-Face Regulation

Legislation to include the home care industry in the determination of eligibility for Medicare coverage for those needing home healthcare has been introduced in Congress. The bipartisan-sponsored H.R. 2663—the Home Health Documentation and Program Improvement Act of 2017—was introduced on May 25 and has been referred to the House Committee on Ways and Means (funding) and the House Committee on Energy and Commerce’s Subcommittee on Health. It needs the industry’s support to keep it moving forward.

The bill amends Title XVIII of the Social Security Act to change the required documentation supporting eligibility for Medicare home health services, among other actions. The goal is to include a patient’s full health assessment regarding the need for home care in the evaluation of eligibility for Medicare-covered home services.

Under the Affordable Care Act, the sole determinant of eligibility has been a physician’s face-to-face encounter with the patient and the resulting documentation from that physician certifying a patient’s need for Medicare-covered home health services. The regulation, as written under “Obamacare,” has resulted in unclear guidance, paperwork overload and delays in getting the needed care for patients, along with confusion among doctors and home health agencies, according to the National Association for Home Care & Hospice (NAHC). It additionally has left the professional assessment from home healthcare specialists out of the equation.

H.R. 2663, introduced in the U.S. House of Representatives by Reps. Earl Blumenauer, D-Ore., and Kenny Marchant, R-Texas, would amend that provision.

H.R. 2663 would direct the Centers for Medicare and Medicaid Services (CMS) to consider a patient’s full health record rather than just the encountering physician’s assessment when determining a claim for home care. Note that H.R. 2663 does not simply repeal the face-to-face physician assessment. (The physician certification requirement is part of the 1965 Medicare law, and all Medicare Part A benefits fall under that provision, according to the NAHC.) Rather, it requires CMS to conduct a full review of the patient’s record—including the evaluation by the home healthcare experts.

The language of the bill is short, stating in part: “For purposes of documentation for physician certification and recertification made under paragraph (2) on or after January 1, 2018, and made with respect to home health services furnished by a home health agency, in addition to using documentation in the medical record of the physician who so certifies or the medical record of the acute or post-acute care facility (in the case that home health services were furnished to an individual who was directly admitted to the home health agency from such a facility), the Secretary shall use documentation in the medical record of the home health agency as supporting material, as appropriate to the case involved.”

One of the great things about home health agency (HHA) evaluations of patients is the completeness of the assessment. Whereas a physician’s face-to-face encounter often reflects a snapshot in time, the HHA does a comprehensive review of the patient’s functionality and health status, providing not only a beginning benchmark but also an over-time review of the progression of the patient’s well-being. This may include records from or statements about the multiple healthcare providers a patient sees—nurses, physical therapists, doctors, occupational therapists, etc. The HHA assessment will likely also include goal-setting, treatment plans and quantitative measures on progress already achieved. The HHA assessment gives texture and context that a simple physician’s exam doesn’t necessarily provide.

A home health agency assessment may also provide critical information on the patient’s home situation including safety, support and accessibility, among other factors. The home health professional often functionally becomes the primary external healthcare provider, and treating physicians rely heavily on the HHA’s reports during the course of care. It makes sense that their expertise be integrated early in the process to help determine eligibility for Medicare benefits.

The Centers for Medicare and Medicaid Services’ original guidance on the ACA requirement was vague and led to improper denial of services containing only a CMS rejection stating the doctor’s narrative is “insufficient,” NAHC argues. About 25,000 such rejections are under appeal. This bill would go a long way in clearing the backlog of appeals. The bill, in addition to including HHA assessments in the original eligibility documentation, also gives CMS the authority to settle the backlogged claims, which—without passage of H.R. 2663—are relegated to a review by an administrative law judge, a potentially lengthy and cumbersome process.

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Sources: NAHC, Congress.gov, NCBI