Face-to-face encounters with patients now required for recertification

Challenges include timing and physician coverage

Reviewing patient data, finding physician coverage and educating staff are some of the activities undertaken by hospices since the Patient Protection and Affordable Care Act mandated the requirement that hospices have a physician see a patient in a "face-to-face encounter" before their 180-day recertification and for each 60-day recertification. Although there was not enough time to include the final provision in the Hospice Wage Index for Fiscal Year 2011, the final details of the requirement were included in the Home Health Agency Prospective Payment System rules released in early November.

"Medicare hospice certification is now a process that includes several distinct components such as the physician's face-to-face encounter, attestations, and narratives," says Judi Lund Person, MPH, vice president, compliance and regulatory leadership at the National Hospice and Palliative Care Organization. "Even though the details were not final until November, hospices knew about the regulation and have been preparing for the January 2011 implementation," she explains.

Face-to-face encounters for recertification are not new to hospice, but the requirement for physician involvement is a significant change, points out Lund Person. Rather than relying upon nursing notes, results of labs, and review of medical records, physicians now must see and talk with the patient themselves or with the assistance of a nurse practitioner, she says.

"The face-to-face encounter gives physicians a chance to lay eyes on the patient and make sure the patient has a chance to ask questions and indicate wishes," Lund Person adds. "It's important that the physician know what the patient does want and doesn't want for future care."

How well hospices can handle the extra burden of physician or nurse practitioner face-to-face encounters for all patients entering their third or subsequent benefit period depends upon a range of factors, says Lund Person. "The physician visit is not reimbursed separately; it is included in the hospice per diem rate," she says. "However, if during the encounter the physician provides a clinical service such as an assessment of symptoms and a change in the care plan to prescribe different medication to control pain or symptoms, the physician service can be billed to Medicare by the hospice."

Hospice managers should be careful to make sure that every encounter does not become a symptom management or billable visit, Lund Person warns. "Many providers with whom I've talked estimate that only about 10% of the face-to-face encounters will include a billable service," she adds.

Lund Person believes the face-to-face requirement will be most challenging for:

• small, rural hospices in areas that do not have a large number of physicians to cover hospice patients;

• hospices with large numbers of long-stay patients;

• hospices in areas in which patients move from hospice to hospice for care.

Rural hospices face challenges

Hospice Services in Phillipsburg, KS, is a prime example of a rural hospice. "Our service area covers 12,000 square miles with a population of less than 60,000 people," says Sandy Kuhlman, executive director of the hospice.

Fourteen employees along with temporary help as needed see an average of 28 patients per day, which means a lot of time on the road, Kuhlman points out.

"Even before the face-to-face encounter required a physician, the role of our medical director increased with the Conditions of Participation," she says. "He has agreed to fulfill the requirements of the face-to-face encounters for recertifications, but our plan is also to hire a nurse practitioner to make the visits that he cannot make. The real concern for rural hospices is that many rural areas are underserved by physician, nurse practitioners, and physician assistants already, and increasing hospice visits for recertification will further reduce the number of hours they are in their offices or clinics."

The medical director for hospice services does have two partners in his private practice, so his private patients still can be seen, but it impacts the physicians' practice because one of them can't take call or see patients when he is on the road and out of his office or clinic, she says.

Initial wording for the face-to-face encounter called for encounters and certifications to take place no earlier than 15 days prior to the beginning of the new benefit period, which would have created a scheduling problem for many hospices, says Kuhlman. "Now, the encounter can occur up to 30 days before the start of the next benefit period, with the actual recertification taking place no earlier than 15 days before the start of the next benefit period," she points out. "The extra two weeks helps the physician schedule the visits."

The preparation for the face-to-face encounters has required time, along with new financial obligations such as increased amount of contract time for medical director and a new nurse practitioner position for the hospice, Kuhlman says. However, once the process is in place, it will not be overly burdensome for her hospice, she says. "The first thing I did was collect data on our patients to see how many patients represent a need for recertification," she says. "For most hospices, one-third of patients receive care for fewer than seven days, and one-half of hospice patients receive care for less than three weeks."

Even if your hospice has a high number of patients who receive care for more than 180 days, the face-to-face encounter can be a positive, Kuhlman says. "It gives us another chance to take a close look, from a physician's perspective, at the care we are providing to make sure we are providing the best care possible," she says.