Deny, Deny, Deny
January 26, 2012
This horse will likely die of humiliation soon but please don't beat her. Her owners have put her through enough already.
It’s Mandy here. Hope you all had a wonderful holiday.
So, we all know the old saying – Deny, Deny, Deny. Well, apparently that’s what our zone contractors are so anxious to do. They deny claims for the smallest little things like medical necessity. Whoever heard? Wink, Wink.
The truth is, these zone contractors get paid literally millions of dollars for ensuring that claims are paid appropriately. In order to make CMS feel good about al those millions of dollars, they have to offset the payment with a whole lot of denials. I wonder how they sleep at night? Probably, pretty good laying on their big fat wallets.
But it doesn’t stop with the Zone. Apparently, Palmetto and other MACs got jealous at all the attention the Zone contractors were getting and now they are flooding the market with ADR’s. In some cases, the same agencies under a ZPIC audit are also getting ADR’s. How can that be fair? It probably isn’t, but we ain’t changing it so we have to live with it.
Palmetto GBA is so warm and fuzzy; they give us a list of the worst offenses. Here are the most recently listed Top 10 reasons for denial:
- Documentation does not support homebound status.
- Lack of response to ADR.
- Information does not support medical necessity.
- Orders do not cover all visits billed.
- Unable to determine medical necessity b/c appropriate Oasis not submitted.
- Medical review HIPPS code change/Documentation contradict M item/s
- POC/Cert present and signed but not dated
- Dependent services denied because qualifying service was denied.
- Partial denial for therapy resulting in medical review HIPPS code change.
- Order not signed and/or dated timely.
What are we dealing with here? Homebound, medical necessity, we know, we know. Apparently, we don’t. 50% of this list is directly related to documentation. Whether it be our Oasis, our skill, or our therapy notes, can we beat this dead horse anymore?
Attention DON’s and case managers! Calling all nurses and therapists!
Big brother is watching. We can no longer skate by with the minimum. We must provide top notch care with top notch documentation EVERY, SINGLE visit for dwindling reimbursement. What does that mean? Only the best will survive, but we can do it.
Steps to take to alleviate denials:
- Train staff based upon the most current guidelines not outdated belief systems
- Make sure employees understand the definition of homebound status and how to document it on every clinical note, including therapists
- Don’t provide an opportunity for a medical necessity denial
- Actually look at medicines every visit – truly groundbreaking idea
- Develop working relationships with physician offices to open communication
- document all changes to the plan of care
- document all changes in condition
- Ask for changes to the plan of care when necessary.
- Always address caregivers in documentation – preferably by name. Changes in caregiver status affect our patients.
- educate all clinical staff to sign and date notes with a legible signature if you are not using electronic documentation
- Train clerical staff to look for signatures and dates when filing as a double check system
- Establish a follow-up policy for outstanding orders and stick to it. Orders not signed within 30 days are not acceptable. Hand deliver to the physician office if necessary.
- Get a custom stamp that reads: DATE YOUR SIGNATURE or something a little less subtle to put on MD orders and care plans
Everyone makes a few honest mistakes, but more than a few could land you in the slammer. Be careful out there my fellow warriors. Document, document, document! Our nursing instructors were right!!
*Please note: No horses were actually hurt in the writing of this blog and I have never actually spoken to or met a zone contractor employee so I actually cannot vouch for their sleeping arrangements, personal appearances or opinions regarding home health zpic audits. This is only a commentary and represents no actual employees of Zone Contractors.
Tennis Lessons
January 22, 2012
Its important to remember that I am not a marketer and as such, I really don’t know what I am talking about but that has never stopped me before and it isn’t going to stop me now.
So, I am a tennis player at heart. I played for years and keep thinking I am going to join a team again but haven’t gotten around to it yet. Truthfully, the competition in league tennis can be overwhelming. If you have never played, imagine a bunch of overly aggressive, middle aged women in short skirts hitting at tennis balls with incredibly expensive graphite as though they swatting were flies. There’s nothing pretty about it.
So that got me to thinking about the competition in general and then in healthcare. Just like tennis, everyone plays the same game and for the most part wears the same clothes. The expensive racket that no one at our level truly needs is very much like the expense budget most marketers don’t need. You might have a decent ground stroke or a killer serve but mostly, we all play the same game on the same courts. A perfectly executed shot sails past the competition and lands out of reach but eventually, one will get one past you. In both tennis and health care marketing, there is not a great margin between the worst player or the best but at least tennis is decent exercise and is a chance to do something with your friends.
Certainly there are differences between the sport of tennis and the deadly serious game of health care marketing but the one that tickles me is wondering what tennis would be like if the balls had a choice of where to go. Wouldn’t that be interesting?
Unlike other industries, we can’t have sales promotions or offer limited time discounts. We can’t underbid the competitors except insurance companies and that usually means taking a hit. I like the idea of a two for one membership to home health or hospice like the local gym offers but the OIG is not impressed with my idea. We end up playing on the same court with same trendy tennis racket with the same short (extremely expensive) tennis clothes and sharing the wins and losses. Why? That’s my question.
Every physician and discharge planner is required by law to pay lip service to patient choice when recommending a co-provider of care and patients for the most part are like tennis balls without a preference. The very fact that we do not appeal to patient choice tells me that we don’t have much respect for our patients’ ability to participate in their care and we almost completely overlook them completely when marketing services.
Obviously, we cannot solicit business from actual patients and again, I am not a marketer but what I don’t understand is why agencies are not doing more for their communities to influence patient choice before the need for care arises. The rules are greatly relaxed when you are marketing to non-patients. What if, when a discharge planner or a physician made a cursory attempt at disclosing freedom of choice, the patient or their caregiver already had a preference for your agency and spoke up?
Here are some of the things I would do:
Start a community falls prevention program open to the public and get other members of the community to participate. Hopefully you will prevent a few admissions but the ones you don’t prevent will already be loyal to you.
Alzheimer’s support for caregivers is has been shown to greatly reduce the burden of caregivers and delay by six months nursing home admission for the patient. The Alzheimer’s Association has opportunities for volunteers and ways for companies to show support for Alzheimer’s Disease patients and their families. If your community doesn’t have a support group, get one going.
You have until Jan 31 to sign up for the 2012 Arthritis Walk. Arthritis is too often accepted as a normal part of aging and patients know this. Be loud and visible about your understanding of arthritis and your efforts to relieve pain and improve functioning of arthritic patients.
The American Diabetes Association is more active than most and considering how many diabetic patients end up in home health, it may be an idea to get active along with your local chapter sooner rather than later. Could you have a foot screening at your local Y open to everyone? It wouldn’t be offering a free service in exchange for referrals because anyone who can get to the Y is not homebound. On the other hand, you could save an extremity from a hospital incinerator if you identify even one person in need of medical attention.
Wear Red on February 3 to increase awareness of heart disease in women. By bringing attention to this cause of the American Heart Association, you will also be bringing attention to your agency and showing – not telling – the community that you are aware of the increased risk of heart disease in women and are prepared to take care of these patients.
This is the short list. Keep searching for local opportunities. Find a nurse who is willing to stay after church once a month and check blood pressures. Volunteer at every health fair you can find in your community. Do basic blood pressure checks at your local homeless shelter. Teach healthy eating at the soup kitchen. Reach out to people who have extremely limited access to care even if they will never be your patients. In doing so, you have gained the respect of your community and frankly, home health has lost a lot of respect lately.
Research shows that job satisfaction increases when people feel as though their company is socially responsible. Most importantly, with extra health care dollars few and far between, you can help improve the lives of the people in your community. So do these things with the intention of making life a little easier for some of your friends and neighbors and everything else will fall into place. And without spending any extra money, you have just added every employee in your agency to your marketing team.
Again, I really don’t know what I am talking about but doesn’t it make sense to look harder at marketing to people before they are patients instead of chasing a ball around the court and waiting for the chance to hit a decent ground stroke?
That Whole Fraud Thing, Again
January 18, 2012
Normally, I do not write much about actual fraud cases because knowing about them does not aff
ect the way good nurses care for patients. I honestly cannot imagine anyone who chooses to be blatantly fraudulent would have an interest in reading my website but who knows? Anyway, I have been following a case in Florida that you might want to keep in mind if you are ever involved with an agency that is not completely above board.
On Jan. 5, three people were sentenced in Miami related to 17M dollars in fraudulent claims being sent to Medicare for home health care nursing and therapy services for patients who were not eligible. This is part of an ongoing legal drama involving multiple patient recruiters, an administrator and a physician being charged or pleading guilty of fraud. Here are the three.
- Lisandra Alonso, 34, was sentenced to 78 months in prison and two years of supervised release and was ordered to pay $15.3 million in restitution.
- Jose Ros, 72, was sentenced to 12 months in prison and three years of supervised release and was ordered to pay $395,000 in restitution.
- Farah Maria Perez, 40, was sentenced to six months in prison and two years of supervised release and was ordered to pay $118,000 in restitution.
Lisandra Alonso was the office manager of ABC home health. In her thirties now, she will be forty when she gets out of jail but then life won’t be so sweet because she will have to somehow come up with 15.3M.
Jose Ros will only go to prison for 12 months but at age 72, that could be a life sentence. I hear prison life ages you. (While I do not approve of patient recruitment, I must admit there is a certain elegance to adding septuagenarians to your marketing team. Kind of wish I had thought of that.)
Farah Perez,40 is the one who really got my attention. Farah is a nurse; just like me and just like most of you.
Now that got my attention. An office manager, a senior citizen and a nurse going to jail. Sadly, Farah is not the first nurse that I have heard of going to jail in recent weeks. It used to be that mostly owners and CEO’s were convicted. Now the rank and files of health care are filling up the prisons.
These three were involved in a scheme where an agency altered clinical records to make people appear to be eligible. In fact, there were records that showed that the patients had impaired vision when they did not or were unable to walk without assistance when they were. In other words, it appears as though they exaggerated the OASIS data in order to increase revenue.
Here’s the kicker. Lisandra, the office manager, was the one who taught the owners and the nurses how to run a fraudulent agency. She emphasized the importance of kickbacks and bribes and taught the nurses how to falsify records.
Nurses, beware. A good office manager is worth their weight in gold. Many have been in homecare long enough to spot certain omissions in clinical records and they are your best friend when it comes to scheduling and payroll. They are perfectly welcome to suggest changes when they see something off kilter. BUT, you do not learn how to take care of patients or document from an office manager.
Anyone who tells you that old people always have pain and impaired vision, is probably right. Look at the OASIS questions. That is not what they ask. You do not apply any blanket answers to questions on the OASIS assessment past the tracking sheet. You assess the patient, you consider the responses, you look them up if you are unsure and then YOU choose the best response.
If you are not satisfied with someone’s advice on how to answer a question, that’s okay. Ask for a reference. I know I do and when nurses ask me to reference something I teach, I am impressed. Those nurses ‘get it’. It doesn’t matter how much they trust me, it is their name on the documentation and unless and until I can prove that I am 100 percent mistake free, I am happy to oblige.
Please don’t let this scare you. Nobody goes to jail for isolated mistakes. On the other hand, it is your responsibility to know the rules and regs pertaining to your position. You cannot claim ignorance if a reasonable person in your position should have known what you did not. For an added layer of protection, call our office to assist you in setting up an effective compliance plan for your agency. But please don’t call unless you are deadly serious about compliance. We do not need clients who aren’t.
Until I achieve the status of 100 percent mistake free, your questions are welcome by posting below or you may email. I’m hoping to achieve mistake free status by June but it might take longer.
Evaluating Employee Evals
January 17, 2012
Pretty much everyone who works is evaluated against certain qualities we desire in employees in addition to the core competencies required for their individual positions. Typically they include knowledge bank, dependability, problem solving skills, communication and teamwork. Scoring is pretty generic as well using a 1 – 5 scale where 1 is poor, 3 is average and 5 is superior. Your agency may do things a little differently but this or something similar is what I see regularly in agencies.
Nobody likes to be average. We like to think we are special and unique and we are. Average simply means that most people are not better or worse in a certain quality or skillset than we are. When talking about nurses, we are, as a group, extremely dependable. Extremely dependable then becomes average. It is the one who suits up and shows up during every crisis and never turns down an extra admit who should get the four or five score.
The example above s what I typically see in agencies. Most employees get fours and fives in almost everything and they get their raise and everyone is happy. The scores of three and below are where attention and resources are devoted to improvement. Realistically, it is difficult to make somebody a better team player or communicate better unless they have a passion to learn what you want to teach.
Here is the same chart with more realistic numbers. Everyone is meeting performance standards except Mary who made too many withdrawals from the knowledge bank. Every employee is above average in at least one area.
Why does this matter? If your goal is to get every employee to score all fives, you will have a homogenous agency with nothing special about it. In fact, if every employee scores a five, it could be said that your agency is average and every score below five is less than average.
You’re employees and their skills are what you sell. Instead of always focusing on what they need to improve to the level of everyone else, would it be better to take the time to find out each individual’s special talents and exploit them?
If you insist on focusing on the weaknesses of an individual, two criteria must be met. The weakness must be so great that it compromises their ability to function in their role and the weakness must be something that can be changed. Asking a chronically shy person to be a better team player or someone who is a little short in the IQ department to perform like an academic is never going to be effective. If the person cannot change and the quality is essential to their job, the person needs to be reassigned to a different position or let go. Or, if the quality is not important to their position, why draw attention someone’s ‘flaw’ that cannot be corrected.
A good manager instead focuses on the individual talents. Instead of getting the average people to perform as well as the top performing individual in an area, he or she will take the people scoring fours and fives and concentrate on talents making them even more valuable to the agency. A great manager will take into consideration even talents that are not work related such as art, writing, calligraphy or music and look for opportunities to exploit them.
We must be standardized in so many areas. There are lines all around us drawn by patient care standards, standardized data sets, billing standards, best practices, etc. that we absolutely must not ignore. Every once in a while, its fun to color outside the lines, or better yet, redraw some lines to make the enclosed space even bigger than it was before.
Or you can work with a bunch of interchangeable drones who are all average in their ability because they do not perform any better or any worse than anyone else in any one area.
Please feel free to email this average nurse if you have any questions or comments but it won’t do any good to point out that my communication skills are sometimes lacking.
Dance Lessons
January 12, 2012
If hell is spelled Z-P-I-C, then purgatory is spelled ADR. If you have been in home care for a long time, you know all about the old FMR process. If you are new to home health, imagine every word you write being scrutinized by someone who wants nothing more than to find that your work is unacceptable and substandard so they don’t have to pay your employer for it. It’s rather uncomfortable.
One of the comments I hear regularly from nurses is that they are not worried about ADR’s or even ZPICs because they have done very well on recent surveys. There are important distinctions between licensing and certification standards so it is entirely possible to have a spotless survey and still have your Medicare dollars at risk. It happens every day.
The recent onslaught of ADR’s is very much like the Focused Medical Reviews in the past but with a few significant changes. So whether you have been around for a while, there are some interesting twists to this new trend.
The most significant change is that agencies are now being told why they are being chosen. There are no secrets. This tiny but remarkable change now means that from the beginning of the audit process, agencies who want to do well can do well.
A ‘probe edit’ starts when your data is significantly different from your peers, usually resulting in more payment to the agency. Here are some of the more important things you should know if your agency begins to receive multiple ADR’s.
- The Medical Review Department of your MAC (FI) requests a total of 20 – 40 episodes that meet the criteria for the edit that has been attached to the agency.
- There is no time limit for the ADR’s to be sent to the agency. It is dependent upon agency billing practices, Medicare census, etc.
- A letter will be sent to the agency for each claim that is under review.
- You have 30 days to send the records to the FI.
- This information is also available through the DDE (billing) system and I strongly recommend that you rely on DDE as opposed to the mail.
- THE SECOND MOST COMMON REASON FOR DENIALS IS FAILURE TO RESPOND TO THE REQUEST FOR ADDITIONAL INFORMATION.
- Once all of the letters have been sent, the ADR’s stop. The edit is put on hold until your claims have been reviewed.
- Do not mistake this lull in activity as an indication that the MAC (FI) is through with you.
- The FI has 60 days to review the clinical records and make a determination about your agency.
- This determination may be made after only 20 records have been reviewed. (This puzzled me but if you are really, really good or really, really bad, the math works.)
- If 77% of your claims are found to meet payment standards, you are usually taken off the radar unless a seriously egregious error suggestive of willful and blatant fraud is discovered.
- If you have a higher denial rate, the dance continues for another round.
- Education is provided by the MAC or FI during this time. It usually consists of memos cut and pasted from the Medicare Benefits manual.
- Whether or not you continue Waltzing with the MAC or get down and dirty with a Zone Contractor who has the ability to take you from purgatory to hell depends on how well you dance.
So, may I suggest dance lessons? If you already know how to dance, then at least make it a point to send in the requested documentation timely. If you go for a second round with a major denial rate (67%), you will find out why Hell is spelled with a Z or worse.
Call us or email us for any questions or assistance with ADR’s. You cannot do anything about being placed on an edit but you can make sure it stops after only one dance.
