A requirement that health care providers have a face-to-face meeting with patients was added as a Medicare payment requirement for home health and hospice care by the Affordable Care Act (ACA). Implementation of the requirement was effective April 1, 2011. The Face-to-Face requirement is intended to be a tool for reducing fraud, waste, and abuse by assuring that physicians or other healthcare providers have actually met with potential home health patients to ascertain their specific care needs.
The Center for Medicare Advocacy initially addressed the Home Health and Hospice Face-to-Face requirement in an Alert dated January 13, 2011. An additional Alert on the Hospice Face-to-Face requirement was published in April of 2011. With the provisions having been in effect for a year, the Center is finding that clients are encountering various challenges resulting from implementation.
A major challenge facing beneficiaries is that some physicians find the certification requirement burdensome, particularly the fact that they are being asked to restate the clinical basis for the need for the prescribed home health care. Their complaint is that clinical information about the patient's homebound status and need for specific services are already in the patient's plan of care, a document that the physician has already reviewed and signed. The Center concurs with the notion that the current iteration of the Centers for Medicare & Medicaid Services (CMS) Face-to-Face certification requirement goes too far. Rather, the requirement should be scaled back to the language of the ACA which calls for the physician or other recognized non-physician prescriber (NPP) to certify that he or she has had a face-to-face encounter with the Medicare beneficiary within a reasonable time frame as determined by the Secretary.
The Center is working with CMS and home health providers to ensure access to home health care services under Medicare and has requested that CMS rework its statement of the Face-to-Face requirement so that its regulatory and manual issuances comply with the language of the ACA. The Center's primary concern is that the Face-to-Face documentation requirements be reasonable and that they do not impede access to necessary home health care services.
Home Health Provisions
The specifics of the Face-to-Face requirement for home health care, and certification after the face-to-face encounter, are included in CMS regulations that were issued on November 17, 2010. The regulations establish that a face-to-face encounter must have "occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care by including the date of the encounter." The certification of the need for home health care must include an explanation as to why the physician's clinical findings support the need for home health care, including that the patient is homebound and the need for either intermittent skilled nursing services or therapy services as defined in 42 C.F.R. §409.42(a) and (c). Regulations provide that a face-to-face encounter can be by tele-health as provided in §1834(m) of the Social Security Act.
The regulations require that the face-to-face encounter be performed by the certifying physician or by the nurse practitioner, a clinical nurse specialist who is working in collaboration with the physician, or a physician assistant under the supervision of the physician, including a physician who cared for the patient in the hospital or skilled nursing facility. The documentation of the face-to-face patient encounter must be a separate and distinct section of, or an addendum to, the certification, and must be clearly titled, dated and signed by the certifying physician. When the face-to-face encounter is performed by a non-physician, he or she must document the clinical findings of the face-to-face encounter and communicate those findings to the certifying physician. (Underlining added.)
If the face-to-face encounter occurred within 90 days of the start of care, but was not related to the primary reason that the patient requires home health services, or if the patient has not seen the certifying practitioner within 90 days of the start of the episode of home health care, the practitioner must have a face-to-face encounter with the patient within 30 days of the start of the home health care.
Recertification of the need for home health care must be provided at least every 60 days, with a preference for the recertification to occur at the time that the plan of care is revised. The recertification must be signed and dated by the physician who reviewed the plan of care. According to CMS, recertification does not require a new face-to-face encounter.
Practical Considerations and Possible Approaches to the Face-to-Face Requirement
- Home health agencies must seek Face-to-Face certifications for all Medicare beneficiaries, including those who are dually eligible.
- It appears that Face-to-Face certification is only required at the actual start of care – not, for example, when a patient switches payment source from Medicaid to Medicare, or upon recertification.
- The face-to-face encounter can be done by a non-physician, but a physician must sign the certification.
- Agencies report having problems getting doctors to sign, fully complete, and/or even respond to requests for Face-to-Face certifications.
- While the Face-to-Face certifications must be clearly titled and include attestation that the encounter occurred and the patient is homebound and in need of skilled care, it does not have to be on a particular, separate form. A physician-signed statement including all the necessary points on a patient transfer form, or Plan of Care, for example, could be a practical solution.
- Medicare contractors should not put form over substance and deny payment when the proper certification of homebound status, skilled care need, and face-to-face encounter exists. The Center will appeal such denials, if encountered by our clients, should they occur.
- The Center will ask CMS if it can authorize the non-physicians who are authorized to perform Face-to-Face encounters to sign the certifications.
- The Center continues to join with representatives of home health agencies to seek assistance from doctors' groups, hospitals, and nursing homes to inform their physicians that they must fully cooperate with the Face-to-Face requirement.
The Face-to-Face encounter offers an opportunity for physicians to be fully engaged with their patients' needs for home health services and provides one mechanism for CMS to monitor Medicare usage to reduce fraud. Implementation must proceed in ways that do not reduce access to home health benefits for people who rely on Medicare. The Center is interested in hearing about the experiences with the Face-to-Face requirement of people using Medicare, their advocates, and their home health providers.
For further information, contact attorney Alfred J. Chiplin, Jr. (firstname.lastname@example.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760, or attorney Margaret Murphy (email@example.com) in the Center's Connecticut office at (860)456-7790.
 See the Patient Protection and Affordable Care Act (PPACA or ACA), Pub. L. No. 111-148 (March 23, 2010),
 See http://www.cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/f2f_listserv.pdf.
 See ACA, §6407(c).
 The Alert addressed this requirement in early 2011, before implementation. See http://cma.benfredaconsulting.com/2011/01/13/new-home-health-and-hospice-face-to-face-physicianpractitioner-encounter-requirement/.
 See http://cma.benfredaconsulting.com/2011/04/28/new-hospice-face-to-face-requirement-help-or-hindrance/
 See ACA, §6407(a)(1)(B). A useful collection of CMS materials on the Home Health Face-to-Face requirement can be accessed at: http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html. Also visit Medicare's Frequently Asked Questions page: https://questions.cms.gov/.
 77 Fed. Reg. 70372-70486 (November 17, 2010). Note: CMS delayed implementation of the face-to-face requirement in the home health and hospice settings until the second quarter of Calendar Year (CY) 2011.
 42 C.F.R. § 424.22(a)(1)(v).
 Ibid C.F.R. §424.22(a)(1)(C).
 Ibid. § 424.22(a)(1)(v).
 Ibid. §424.22(a)(1)(v)(A).
 Ibid. §424.22(a)(1)(v)(B).
 Ibid. §424.22(b)(1).
 75 Fed. Reg. 70372, at p. 70428, (November 17,2010). ). See CMS' response to a public comment: "We note that the Congress enacted the requirement to apply to the physician's certification, not the recertification. Therefore, we have interpreted this provision to apply to the initial certification only." Ibid
 See 75 Fed. Reg. 70372, at p. 70428 (Nov. 17, 2010).
 See 126.96.36.199 – Face-to-Face Encounter (Rev. 139, Issued: 02- 16-11, Effective: 01-01-11, Implementation: 03-10-11), Pub 100-02 Medicare Benefit Policy, http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R139BP.pdf; http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R68GI.pdf. The manual provides that the certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient. Certain NPPs may perform the face-to-face encounter and inform the certifying physician about the clinical findings exhibited by the patient during the encounter. NPPs allowed to perform the encounter are: a nurse practitioner or clinical nurse specialist working in collaboration with the certifying physician in accordance with State law; a certified nurse-midwife as authorized by State law; a physician assistant under the supervision of the certifying physician. Ibid. See also, §6407(a)(1)(B) of the ACA.