Face to face MD visits

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Our agency has a couple of patients who have not been seen by their primary MD for over a year now. The doctors keep renewing their medications and signing off on our orders and recerts. We are "threatening" to close their cases if they don't manage to get to their MD, or their MD come to them. We are sending reminders to the MDs about the law. It's getting down to the wire now for one patient in particular. How is this being enforced! What with patients going to hospitals and being treated by hospitalists (hate this) and still not being seen by their primary, what do you do?

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Specializes in Nephrology, Cardiology, ER, ICU.

I'm an APN and work in nephrology. When I do a referral for HH - I do the face the face.

Does this physician have an APN working for him?

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Specializes in COS-C, Risk Management.

Reminder that for Medicare patients, the physician still has to sign the face to face form, even if the non-physician provider saw the patient and fills out the form.

Also, keep in mind that you cannot bill Medicare if the face to face isn't completed within 30 days of admission to the home care agency if the patient did not come to the agency with a completed face to face encounter.

Hospitalists *can* sign the face to face encounter, but they must designate the physician who will follow the patient after discharge. Enlist the assistance of the hospital discharge planners to obtain the face to face and refuse to accept patients from hospitalists if the face to face does not come with the patient.

And if the patient hasn't seen the physician in over a year, why are you continuing to recert? Has the patient had a change in condition that warrants recert?

http://www.cms.gov/HomeHealthPPS/Downloads/HH_Face_to_Face_heads_up_notice.pdf

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One is a patient who has a suprapubic catheter that gets changed q 3-4 weeks, and is a paraplegic. It is difficult to get him in to the doctors, plus, the office is not equipped witha lift, making it impossible for the MD or APN to do any real assessment! His MD has made one home visit - last year - and he was in a respite care center for a month and came home the end of March. He was seen by an MD both in the ER and respite center, but not his primary. He and his wife are in their late 80's.

The other patient is a quadraplegic who has a very bad decub on his coccyx, weighs over 350 lbs and his family can't get him in a wheelchair. They have a lift, but the lift doesn't sit him straight in the wc requiring them to try and lift him into the seat. Not a good plan - can also cause further damage to the wound. Furthermore, his MD doesn't have a lift in the office either in order to get him on a table to be able to assess the wound. Now finally, the MD is working to get him approved for an ambulance transfer to the office, whereby he'll be on a guerney, allowing them to be able to turn him enough so it can be assessed.

After informing the wife of pt #1 about the law requiring him to have face to face visits with his MD, she said she is going to contact the "handicapped" assoc and have them start some kind of push to inform doctors that they need to have appropriate equipment on hand to accommodate these kinds of patients!

Can a visit by a NP or PA qualify as a face to face visit? Maybe the doctor groups need to look into that as a plan.

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Specializes in Home health, Cardiac Tele, Doc's office.

You are not required to recert a patient at the end of the cert period (or at least I've been told that in several different agencies I've worked). Where do you live? I live in Arizona and AZ and CA I know certain areas have Mobile Doctors that go to the homes and manage patients that will sign the F2F. Also if they are not going to the doctor and the doctor won't come to them and if you can't get F2F signed then your company is not going to get paid for that episode. At least this is my understanding and I've been known to be wrong once or twice.

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So, we just "abandon" our patients because they have lazy or overworked doctors? In our case, we live in a mostly rural area and getting around is a challenge for a lot of people, expecially the elderly. What would you do - just "dump" them? We don't have mobile doctors here in the foothills in central Ca.

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Specializes in COS-C, Risk Management.

Well, let's see. You comply to the letter and spirit of the law, you close because you can't bill, or you get closed for fraud. Your choice.

CMS has indicated that HHABN option 2 is for use in a situation where the patient cannot/will not comply with face to face encounter requirements. Use it.

Otherwise, alter your care plans to meet the needs of the patient and the agency. Medicare home health is not intended for long term use. If you are keeping patients that long, it *is* an abuse of the system as it was intended. Direct these patients to a Medicaid waiver or nursing home diversion program. Get an MSW involved. Make changes. If you always do what you've always done, you'll always get what you've always got.

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Specializes in Home health, Cardiac Tele, Doc's office.

Very well said Kate. Unfortunately some cases you have to cut your losses. Getting closed for fraud, the company closes because they can't afford to stay open you lose your job because your patients are not complaint or you (your company) do not recert the patient at the end of the cert period. I understand as the nurse you want to make sure the patient is cared for, but bottom line is no F2F, no money. Home care companies are closing all over the US for those very reasons, hopefully yours won't be one of them.

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We are not charging these patients, nor are we sending bills to Medicare. Some people we keep on as "charity" cases because if they go to nursing homes, which means a minimum of an hour drive for their family to visit, if they have transportation, they will be pretty well isolated. There has to be a way to address these types of clients because we see this happening more and more in the rural areas. I guess the plan is to just let them die so they won't be a "bother" anymore. We are able to get their doctors to sign orders, so we are not out of compliance as in working without orders.

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Specializes in COS-C, Risk Management.

If these are not Medicare or Medicaid patients, they are not subject to face to face rules. Make sure that your agency has a charity care compliance plan and that you are meeting all requirements for compliance. I'm not sure why face to face is such an issue for you.

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Specializes in Home health, Cardiac Tele, Doc's office.

If you aren't charging these patients and you aren't billing Medicare, why do you care about the F2F?

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If they have been on service prior to the start of F2F, they are not subject to needing a F2F encounter, whether they have seen the MD or not. Only patients started after the inception of F2F require it.

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