Are ADRs Coming at Your Agency Fast and Furious?

Due to a CMS (Centers for Medicare and Medicaid Services) directive known as “Probe and Educate” your agency has had experience directly with ADRs. This has resulted in five ADRs focused on Face to Face (FTF), in particular, and many denials have ensued.

Approximately 12,000 Medicare certified home health agencies have or will receive five ADRs from the MACs (Medicare Administrative Contractors) focusing specifically on FTF. CMS’ goal is to identify how home health agencies are complying with all of the revised FTF requirements. Eventually, all home health agencies across the nation will be included in the ADR probe focused on FTF.

The Probe and Educate initiative has some pretty stringent guidelines. With this process, if an agency has received two or more denials in its group of five ADRs, it has failed the probe. Failure results in another five ADRs being issued for this agency.

After an ADR is denied, the MAC will send a letter to the home health agency detailing out the specific reasons for the denial as well as a few recommendations. It is advised that the home health agency speak directly to the MAC regarding the denial. This is recommended especially if the home health agency has supplied the appropriate and compliant documentation, and it is present. The home health agency does have the right to appeal the denials in the FTF probe. However, the bad news is that the second round of ADRs does not stop for the appeal process.

In my opinion, Face to Face is the most difficult regulation that home health agencies must deal with and that is saying a lot! In the past decade, the home health industry has been through so many regulation changes and it is very amenable in most instances and goes with the flow. However, with FTF there is a big issue and that is that CMS penalizes home health agencies for what physicians fail to document. Yet the home health agencies do not have any control over physicians’ documentation.

For example, to have a physician document homebound status is extremely difficult since it is not standard physician documentation. In addition, they are not educated on the types of homebound status definitions and the documentation necessary to prevent denials. With that being said, there are some physicians who have been extremely conscientious about learning what to document for FTF for home health agencies and in the physician’s clinical records. Unfortunately, they are not always compliant with the scrutiny of the auditors.

The simple fact that a FTF encounter can occur 90 days prior to a homecare admission is an issue. When a physician sees a patient due to CHF (Congestive Heart Failure) in her/his office on day 89 before a patient exacerbates, has medication changes, becomes homebound and is admitted to home health demonstrates the flaw. The patient is admitted for CHF; therefore, that FTF visit 89 days before home health referral is allowed. However, we must remember the patient was not homebound then. Unfortunately, this is ripe for denials!

Ideas to Improve the Situation

You may ask as a home health agency administrator how should I deal with the FTF issues resulting in denials on ADRs? There are a few things that can be done to improve the situation.

  • Physician Education – This needs to be an ongoing educational process for not only physicians, but also their key staff. It needs to include examples of how homebound status should be documented, what skill is needed for homecare and the estimated need for continued services on re-certification. All of these are key!
  • Tight Agency Processes – These should be implemented to ensure that the FTF encounter was completed in the timeframe allowed. Also the appropriate physician documentation on the encounter is in the clinical record of the physician and the home health agency.
  • Clinical Review of Documentation – It is critical that the FTF documentation is compliant and in real time.

We Can Help!

Our 5 Star team offers vast experience with ADRs. To start with, here is a link to a presentation on FTF. It includes further details on this critical topic. In addition, we can help ensure your home health agency’s documentation is compliant on an ongoing basis. If your agency has received an ADR already, our experts can help you to review the clinical record in order to identify the vulnerabilities you may have regarding these ADRs and denials. This will help prevent future denials too. Email us at [email protected] or give us a call at 866-428-4040.

Southern Web SupportAre ADRs Coming at Your Agency Fast and Furious?
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