Problem Solvers

Face-to-face: Are You Ready?

Despite an unknown enforcement, how should providers prepare?

• By Joseph Duffy
• Jan 01, 2015

For several years, providers have been rapidly pushing into retail sales. As competitive bidding has become increasingly “real” as Round Two is approaching a re-compete and CMS has announced it would take bid prices national by 2016, providers have paid similarly increasing attention to retail sales. Many providers are now seeing retail sales not as a bonus, but as a business imperative. Simply put, it drives new, desperately needed revenues that can help compensate for the cash flow cuts caused by constantly dwindling Medicare reimbursement.

In the wake of the face-to-face rule, which states that for certain specified DME items an in-person, face-to-face examination documenting the need for the item must have occurred sometime during the six months prior to the order for the item, providers cannot forget that enforcement of the rule can come any day. And for those who are unprepared, this can be a big enough burden to affect your business.

The ACA 6407 face-to-face ruling was placed into law and implemented July 1, 2013. The DME MACs — responsible for processing Medicare Durable Medical Equipment, Orthotics, and Prosthetics claims for a defined geographic area or jurisdiction — started auditing on the written order prior to delivery (WOPD) requirement for dates of service effective January 1, 2014. The DME MACs are not auditing on the face-to-face encounter requirement; however, other auditing entities are able to enforce this requirement.

“What this means to providers is that the DME MAC won’t audit on the face to face but others may audit the requirement to have a face to face within six months from the date of the WOPD,” said Dan Fedor, compliance specialist for VGM/US Rehab. “Originally the DME MAC stated that the CERT was the only entity that could audit even though an official start date has not been published by CMS other than that it will be some time in 2014. If not already doing so, providers should begin to obtain a face to face within six months from the date of the WOPD for all specified products listed on the ACA immediately.”

CMS has indicated that the face-to-face requirement will not be applied retroactively once the delay is removed.

“The risk today is with the CERT contractor who would deem an audit to fail if the face-to-face requirement is not met,” said Kim Brummett, vice president of regulatory affairs for the American Association for Homecare. “However, as the MACs are not enforcing the requirement, a supplier could appeal a CERT denial through redetermination and assuming the only issue is the face-to-face requirement, the denial should be overturned. However, all DME requires proof of medical necessity and, therefore, suppliers are obtaining medical records typically from office visits and hospital discharges that would meet the face-to-face requirement if documented appropriately.”

Experts agree that to avoid the consequences of enforcement, providers should have procedures in place today to meet the impending enforcement of the face-to-face requirement. They must implement a protocol within their company requiring a copy of a face-to-face encounter and WOPD for specified items listed on the ACA. They should continue educating ordering physicians that this is a requirement and that the product ordered cannot be delivered without meeting these requirements. It all comes down to having procedures in place, which Fedor outlines below:

Step 1: Know the specific products/codes of face-to-face items. Some of the products on this list include manual wheelchairs, various manual wheelchair accessories, hospital beds, TENS, nebulizer and many more. For a complete list please go to go.cms.gov/1uK082s.

Step 2: Continue to educate physicians about this requirement. Inform physicians of the requirement and provide them with a copy of the Dear Physician letter from the DME MAC Medical Directors. You can obtain a copy at bit.ly/1swCBrM.

Inform physicians that no DME provider can provide any of the products on the ACA list unless all requirements have been met with copies received by the DME provider PRIOR to delivery.

Step 3: Confirm that all requirements have been met prior to delivering one of the specified DME products

• The face-to-face examination must document that the beneficiary was evaluated or treated for a condition that supports the need for the DME ordered.
• The in-person visit occurred within six months from the date of the order for the item.
• The face-to-face examination was co-signed and dated by a physician (MD or DO) if a PA, NP, or CNS performed the face-to-face encounter.
• The date on the order wasn’t written prior to the face-to-face encounter date.
• The order contains all required elements:
  • The beneficiary’s name
  • The physician’s name
  • The date of the order and start date if the start date is different than the date of the order
  • Detailed description of the item
  • Ordering physician’s NPI
  • The signature of the ordering practitioner
  • The signature date of the order
• For specific items provided on a periodic basis please refer to the Dear Physician letter for additional details: bit.ly/1swCBrM.
• Obtain a valid face to face and a WOPD prior to delivering the product.
• Ensure all documents are date stamped to prove receipt date.

If a provider has not obtained all required documents or one of the documents is not valid, it should not deliver the product; otherwise, it will be at risk for recoupment in an audit. Visit cms.gov for more information.

This article originally appeared in the January 2015 issue of HME Business.