Is There A New Round of Face-to-Face Physician Encounter Audits?
NAHC’s face-to-face lawsuit still pending in Federal court
October 1, 2014 03:23 PM
New England-based home health agencies are reporting what appears to be a new round of audits of Medicare home health claims focused on compliance with the face-to-face physician encounter rule by the Medicare Administrative Contractor, NGS. These audits involve prepayment reviews and high-dollar claims appear to be the primary targets. HHAs report that claim denials include the sufficiency of the physician narrative and a rejection of added face-to-face supporting documentation that is composed after the claim submission.
NAHC has not yet had comparable reports of renewed face-to-face encounter audits occurring outside New England.
This action follows CMS’s recent letter to Congressman James McGovern (D-MA) that rebuffed his requests that CMS suspend audits related to the physician narratives and restore payment on claims previously denied for insufficient physician narratives. The McGovern effort was part of a broad-based congressional request from a bi-partisan group 0f House members to the Administrator to remedy the past face-to-face encounter denials in the wake of the CMS proposal to abandon the physician narrative requirement.
The September 9, 2015 letter to Congressman McGovern from CMS Administrator Marilyn Tavenner states that while “CMS has not approved Recovery Audit Contractors to review documentation on the face-to-face encounter for home health,” the Medicare Administrative Contractors (MACs) and the Supplemental Medical Review Contractor can continue to review home health claims on all bases to determine compliance.
The Tavenner letter rejects any payments for previously denied claims stating, “ CMS cannot allow for full payment of claims that were previously denied for an “insufficient physician narrative, “ as CMS must make claim payment determinations based on the rules effective for the date of service in question, and the Home Health PPS rule has not yet been finalized.”
CMS had earlier rejected NAHC’s attempts to secure a settlement of its lawsuit challenging the face-to-face rule as it relates to previously denied claims and ongoing audits. The Tavenner letter is consistent with the litigation position taken by CMS – that it will not consider a retroactive rescission of the physician narrative requirement nor offer clarifications of that part of the face-to-face rule that could lead to payment of many of the previously denied claims.
NAHC continues to expect that CMS will finalize its proposal to eliminate the narrative requirement from the rule. The CMS proposal to require physicians to maintain sufficient documentation in their files to support the face-to-face certifications remains an industry-wide and physician community concern. Commenters on the proposal uniformly recommended that it be withdrawn.
The NAHC lawsuit on the face-to-face rule remains before the federal court in Washington in an effort to address the ongoing audits and past claim denials.
NAHC will be filing a brief in response to the CMS efforts to have the court reject a hearing of the case on October 10. The expected date for issuance of the rule change eliminating the narrative requirement is between October 31 and November 3.
NAHC recommends that HHAs take all appropriate steps to secure “sufficient” physician narratives until the rule change takes effect and to pursue administrative appeals on any claim denial that the agency believes to be unwarranted.