Reduce Claim Denials Under RCD with a Strong Face-to-Face Compliance Program

Review Choice Demonstration (RCD) is in full cycle in Illinois, Ohio, North Carolina, Florida, and Texas. In June 2021, Palmetto GBA posted the top 5 reasons for non-Affirmation and claim denials. The top 3 were related to the Face-to-Face (F2F) encounters, reasons being:

1. The F2F encounter was not related to the primary reason for home health services
2. The F2F encounter note was missing
3. The F2F encounter was untimely and/or the certifying provider did not document the date of the encounter

For those agencies in the remaining 45 states, not participating in RCD, you can anticipate continued Additional Development Requests (ADRs). All MAC’s (CGS, NGS, Palmetto GBA) report the primary reason for claim denial as “failure to respond” to the ADR, followed by “Certification Missing/Incomplete/Invalid”, which encompasses the face-to-face encounter. If you find that your F2F errors correlate with some of these common reasons, providing clinical oversight will often circumvent this.

Review your Referral Source

The source of your F2F referral is critical because it will determine who is qualified to complete the clinical note and who must sign off on it.

If you have a community referral:

• A Physician or the allowed Non-Physician Provider (NP, PA, Certified Nurse Midwife, or Certified Nurse Specialist) can complete the F2F encounter. must be signed by the same physician or provider.

If you have an acute or post-acute facility referral:

• The facility Physician or their Non-Physician Provider can complete the F2F encounter. The SOC and POC may be signed by the same person, however the Certifying Provider must acknowledge that they have properly reviewed the encounter. This can be captured in a few ways:
  • Include the F2F date on the plan of care
  • Obtain a separate attestation from the certifying physician attesting to the F2F date
  • The certifying physician’s dated co-signature on the F2F encounter note

TIP: An agency must ensure that the POC is addressed to the provider that will be signing.

F2F Encounter Documentation Requirements

• It must be signed and dated by the provider who performed the visit, which is usually an office visit note, an inpatient progress or consult note, or discharge H&P/summary
• F2F is required to be related to the primary reason for home health
• It must support the patient’s homebound status
• It is necessary to support a Skilled Need or Medical Necessity
• The F2F must be within 90 days prior or 30 days after the SOC date

Due to the COVID-19 public health emergency, F2F encounter visits may be done via telehealth. However, it is important to note that they require an audio and visual format that allows two-way real time communication between the provider and patient. This includes, but is not limited to, platforms such as Skype, Zoom, or other similar methods. A phone call is insufficient and does not meet the telehealth requirements.

TIP: A Completed F2F Certification Statement is not a F2F Encounter. The F2F Encounter includes a comprehensive assessment. It is recommended that the agency coder must have the F2F encounter note to code accurately.

In addition, the CARES Act that was implemented in March 2020, has created permanent changes to F2F encounters. CARES Act allow Nurse Practitioners (NPs), certified Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) to certify beneficiaries for eligibility under the Medicare home health benefit and oversee their plan of care. As a reminder, NPs, Pas, and CNSs have previously been allowed to complete the F2F encounter documentation, but not certify the patient for home care or sign the Plan of Care or other orders. You should still consult your state practice acts prior to accepting orders from NPs, CNSs, and PAs.

As home health agencies continue to tackle RCD, it is key to not let F2F workflows go unresolved. Take the time to rework your processes, implement best practices into your culture, and make it a high priority to reduce claim denials sooner rather than later.

Learn more about McBee Review Choice Demonstration Services and McBee ADR Compliance & Pre-Bill Review Services