Revalidation
February 7, 2012
Everyone needs validation sometimes. I especially like it when my parking gets validated. Some people need their feelings validated. My driver’s license could use a little revalidation since it has expired and everyone loves a valid credit card. Medicare has also jumped on the validation bandwagon with a new requirement for revalidation 855a’s.
Raise your hand if you have no earthly idea what I am talking about. Good. You can quit reading now unless you own an agency or serve in a managing role. This includes the DON, CFO, Administrator, etc.
As some of you may have figured out by now, CMS has had a little issue with fraud and abuse over the past couple of years. Why just last week two more people in my little town of Baton Rouge were arrested. Many times, these ‘fraudsters’ as the FBI likes to call them, are not much more than shams. When the Feds go to arrest them, they aren’t even there.
So, in an effort to keep track of all their little contractors, CMS is now in the process of sending out letters to all providers asking for same information that would be provided for an agency enrolling as a provider. Furthermore, they are holding agencies to standards that may not have been in place when the agency was initially certified for Medicare.
This is not a complicated process. Any rocket scientist can figure it out. You just fill in the blanks and send it in. You have to pay first on the website. Some folks can even do it online. But if your organization is simple and the ownership structure is fairly normal, it is completely doable.
Here are some things to remember:
- Do not send in a revalidation 855 until you are asked. I have a list of all providers who have received a letter. If your mailman is as confused as mine, drop me an email or send me some chocolate and I will look you up.
- The ability of contractors to cross reference databases is phenomenal. If you have ever, even tangentially been associated with a person or provider who has been on Medicare’s naughty list, contact your healthcare attorney (or mine) prior to submission of the 855a to determine your risk. Failure to disclose something that Medicare deems relevant is the provider’s equivalent to cyanide.
- Go for perfection. All typos will be discovered and brought to your attention as though they were blatant attempts to commit fraud.
- Do not ignore your letter. This is not an option or a request from Medicare. If you fail to complete your revalidation 855a, you may very well find yourself unable to bill Medicare, Medicaid and a whole lot of other payor sources.
- Know the legal name of your agency. Don’t laugh. You would be surprised how many people do not know the legal name of their agency.
- If you are asked to sign a certification page and you do not own the agency, read it very, very carefully. You are signing that you are responsible for all activities within the agency and will ensure that they meet all Medicare Guidelines.
If you need help with your 855a, Alice Posseno, the quiet consultant at Haydel Consulting Services knows more about Medicare enrollment than anyone on the planet. I have no problems renting her out for your project.
Getting Paid
January 30, 2012
I see a lot of denials in my job. Some (actually a lot) are legitimate because the agency hasn’t complied with one or more regulations. I have also seen an alarming rate of denials that cause me to question the competence of those performing the reviews.
Last week I received a copy of a denial. It was actually the second denial on the same claim. Palmetto GBA originally denied the claim as they did not think that the Alzheimer’s patient confined to a wheelchair was homebound. My client appealed to Maximus who agreed that the patient was in fact, confined to the home but then denied the claim because there was no documentation of the face to face encounter. The reason my client did not send the documentation is because the episode in question was the second episode and the face to face encounter occurred prior to the first episode.
I am also seeing claims denied because of physician signatures. In some states, my own included, the signature requirement in the minimum standards reads that if the agency documents when the orders were received by the agency, that will suffice as evidence that orders were received timely according to state minimum standards.
The state does not pay your Medicare Claims.
Medicare requires that the physician both sign and DATE his or her signature. Failure to do so will result in a denial.
Statutory Denials
Statutory denials are like free spins on the slot machine for the folks who review ADR’s and other claims. A statutory denial means that the patient was somehow not eligible for services and therefore, nothing is covered. Compare that to a denial because the reviewer did not think that two of the visits were covered. If the total number of visits was greater than 6, then the two non-covered visits will not result in a loss to the agency. If an ICD-9 code is not supported, the payment will be downcoded usually costing the agency a couple of hundred dollars. But if the patient is not homebound, or there is a problem with the physician, or the orders are not signed, the claim is denied in its entirety and no further effort is required by the person doing the review.
Now, if it were me and y’all can thank your higher power it isn’t, I would go for the statutory denials every time. (And I could find them, too.) These are also the easiest to prevent.
Getting Paid
- Everyone in the agency should be aware of the signature requirement. The primary responsibility should lie with the first person who sees the orders whether it is the marketer or the person receiving the mail. However, nobody should see an undated signature without bringing it to the Director’s attention.
- Be obnoxious about dates. Buy some file folder labels and print, ‘Please sign and DATE your signature’ at the bottom of every order. Use red ink. Make it interesting and noticeable. Add a note about dating signatures to your fax cover sheet used for orders.
- Because marketing staff often have more exciting things to discuss, make badges that read: I need a date. That will spark some lively conversations.
- With every ADR that is submitted to your MAC, include the description of homebound status as found in the Medicare Benefits Manual.
- After the patient’s initial episode, ensure that the face to face encounter is included in the summary. That leads me to;
- Write a summary. If your agency is not writing summaries for each episode, begin writing them now. For ADR’s there is nothing wrong about documenting after the fact as long as the documentation is dated on the day that you wrote it.
- If you find an egregious error that cannot be ethically corrected, cancel the claim and send documentation along with your ADR. This won’t affect the outcome but it is the classy thing to do. It also shows that you do know how to recognize errors. Please note that some errors can be corrected ethically. Do not be too hasty in cancelling claims.
- If at all possible, have someone who has not been involved with the patient review the documentation you intend to submit. It is too easy to read between the lines when you know about the patient. The holes are not glaring to you. If you have a branch or if there is an another agency owned by the same organization, trade off ADR’s. If you do not have a sister agency or anyone in your organization, consider using a professional consulting service. I can recommend a good one if you need one.
- Write a cover letter if there are any discrepancies in your documentation. For instance, you may have a very weak patient who progressed to her highest level of functioning with therapy in a prior episode. Note this so the chart does not look as though you have a patient in need of therapy but failed to provide it. (Yes, the reviewer should be able to look at past claims but they should also know homebound status and when the face to face encounter occurs as well.)
- Share your ADR results with your staff. It is so much easier to learn from the errors of others. Too often, agencies don’t want word to get out on the street that they have received a ton of ADR’s. Get over it. ADR’s are being sent out at a rate that might very well save the United States Postal System from financial ruin.
We are always interested in hearing about those strange and somewhat inappropriate denials. Please share with us if you have one that we might teach us all a little something about getting paid. After all, it doesn’t matter how much congress reduces the home health payment if you are never paid.
And as always, we are available to help with ADR’s. We read clinical records as though payment is coming from our own pockets (because it is!) and do our best to get you paid. Mind you, we can only work with what we are given. So, write those summaries and get signatures dated.
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.
Home Health Nursing Resolutions
January 1, 2012
I know how busy everyone is during the holiday season so I took it upon myself to write some resolutions for you. You can click on the picture and print the short version if you don’t want to read the explanations. Please note that I did not specify these are New Year’s Resolutions. They are good for any time of the year that you are not finding personal satisfaction from your work.
I resolve to recognize my skills as insignificant.
The traditional definition of a skill refers to the ability to do something well such as a task or a technique, usually as the result of practice. Face it, most heroin addicts can start an IV and those blood pressure machines at WalMart are pretty accurate. Our value does not come from what we can do although I hope you are skilled at CPR if I fall out in front of you. Our value comes from nursing judgment and knowledge. There’s always the possibility that an unconscious cardiologist on the floor in an empty room is merely napping on a hard surface due to back problems after a long night on call. (Yes, I called a code.)
I resolve to take responsibility for my ongoing education.
Do not wait for your employer to spoon feed you what you need to know. Educating nurses in home health is an expensive nightmare. Furthermore, you cannot function without knowledge of OASIS and PPS and Medicare Coverage guidelines so they get first priority in the education budget. None of those areas of expertise make you a better nurse. Learn about a new disease or re-visit one that affects many of our patients. I see documentation that reflects a serious lack of knowledge about the medications patients are prescribed. Since skills don’t make you special, go for knowledge. Collect on a daily basis the information you need to make intelligent decisions about when to deploy your skills. Sadly, if you don’t take responsibility, no one else will.
I resolve to be grateful for all referrals.
Nurses who get paid salaries in the office have been known to sling a little attitude when a new referral comes their way. To them, it is more work and when a referral source does not have the information they need right away, they are offended. 2012 is a whole new world in home health and nursing is going to be at or near the frontline of marketing. If your agency does not have a steady stream of new referrals and the ability to take care of them, you won’t be reading my blog next year at this time. And remember, it’ all about me. I like my readers.
I resolve to treat my coworkers with respect and compassion.
I have made mistakes in my career like giving a handful of psychotropic medications to the wrong patient. I have lost a bag of Pavulon in the ICU (still hasn’t been found). I have forgotten lab and once gave a patient who was allergic, morphine. Nobody died except a little piece of me. (The patient who was doing that flash pulmonary edema thing actually got better as a result of the morphine.) Doing something that can potentially harm a patient is the worst feeling in the world. If it were not for the compassion of the experienced nurses who offered comfort more than chastising, I would have gone to work at Taco Bell a long time ago. Save the chastising for poor or late documentation. Of all the mistakes I have made, I can honestly say that I have never made the same mistake twice.
I resolve to watch what I say.
Gossip and complaining can destroy an agency faster than a ZPIC audit in a dirty agency. To determine if you are repeating gossip or complaining, ask yourself if the person who is hearing what you have to say is in a position to change the situation. If not, be a class act and keep the information to yourself. If you feel the need to ‘vent’ or ‘share’ remember that is your need. What is perfectly acceptable in a support group or in therapy is not always professional behavior especially when the feelings of your coworkers are at risk. (It just now occurred to me that we should have a 12-step meeting for home health employees…….)
I resolve to keep in mind that Nursing is a profession.
It bothers me when I see people in loose scrubs and dirty shoes on the street and I have to look hard to determine if they are escaped prisoners or healthcare professionals. I would like to offer thanks to the state of MS for changing their standard prison wear to bright green and white stripes for exactly that reason. It also bothers me that some of our communication with physicians is less than professional because we are not prepared or concise in our information and questions. When visiting patients, we similarly need to be prepared with wound care materials, teaching tools, etc. I would fire any professional I hired who was not prepared when I was paying for their time.
I resolve to be grateful.
The benefits of gratitude are not some new-age, hippy sort of thing. There have been numerous scientific studies with astounding results. Take the time to click on the hyperlink and read about some of the them summarized in the New York Times prior to Thanksgiving. Next, go buy some ‘thank you’ notes and find a reason to write one everyday. By actively searching for reasons to be grateful, you will change your whole perspective on life.
I resolve to live the life I want my patients to have.
We teach our patients to eat well, exercise, take their medications and in general do what it takes to remain in their homes for as long as possible. Although you are significantly younger than most of your patients, you probably would not have met half of them if they had started practicing what you are preaching when they were your age. On the other hand if you are as old as most of your patients, you probably already know this.
I resolve to have fun!
Your patients are an endless source of entertainment if you get to know them. Find out who thinks the Moon Landing was propaganda by the government. Ask them about the town fifty years ago or the first president their vote helped put into office. How did they meet their spouse? (Hint: it probably wasn’t at a bar or through an online matchmaking service.) Collect the details that make your patients worth knowing. Vital signs do not do it for me.
If you are periodically overwhelmed with paperwork, find someone else in the same boat. Meet up at a coffee shop early in the morning and help each other get caught up. It is always easier to clean someone else’s house than your own. It is the same way with paperwork. It is easier to see what is missing in someone else’s. Make getting caught up a social event.
Listen to music between visits and sing as loudly as you can.
Clandestinely give small presents to your least favorite coworker. Not knowing who gave them the chocolate or scented candle, etc. will make them be suspicious of everyone and they will feel compelled to be nice to the entire office. Plus its fun to watch someone who is difficult to get along with accept an act of kindness. Usually they don’t and that’s funny, too. Rarely, but enough to make it worthwhile, they drop their defenses and you find out they weren’t who you thought.
Once a year, play hooky. I mean it. Take the day off and go to the movies and do some shopping or take a nap. Go hiking in the woods. Do whatever it is you do when you are not working and do it with gusto. It also helps put things into perspective if you realize that the entire world does not fall apart without you for one day. Being a responsible nurse 364 days a year is enough. So only one day a year, play hooky but don’t get caught! If you do, I will deny everything.
As we begin another round trip around the sun, please accept my sincerest thanks for being such wonderful travel companions. This is the first blog post of 2012. I wonder what the last one of the year will read.
Happy New Year from the Haydel Consulting crew.
How to Reduce Hospitalizations
December 13, 2011
First of 
all, I am getting some really good information from the Medicare 101 quiz posted Sunday evening. When the responses stop coming in, I will share some of the more interesting results with you. It will certainly give us some useful information to use when writing posts in the future.
As I suspected, Coumadin should be a schedule II medication controlled to the same degree as Oxycontin and other medications that shouldn’t be distributed freely due to the risk of untoward side effects up to and including death. Now, I have proof. Medscape has a new, very short CE activity that offers evidence to support my position.
After reading the CE article, I am sure you will agree with me that the best way to prevent unavoidable hospitalizations is to discontinue Coumadin on all of your patients. Seriously, if I was an ambulance chasing lawyer, I wouldn’t spend money on TV commercials for my law practice. I would advertise Coumadin. If your stodgy MD’s don’t agree with my assessment, at least consider upgrading your communication processes related to Coumadin.
(By the way, in case you think Pradaxa is the answer, you may want to rethink your position. Four days ago, the FDA issued this warning about Pradaxa. I only skimmed through it but I believe it said something about post marketing reports of bleeding putting the patient at risk for hospitalization or even death. That is never good and almost always messy.)
So I guess that leaves us with good old fashioned nursing care as a solution. Consider using SBAR-C communication when communicating with others about Coumadin.
- S – Situation
- B – Background
- A – Assessment
- R – Recommendation
- C- Communication
Example:
Situation: I just drew lab on Ms Smith as ordered a week past her last dosage change of Coumadin. She is currently on 7.5 mg daily and her INR is now 4.2.
Background: She had a mechanical valve replacement two years ago and did fine on her Coumadin until recently. Her INR’s decreased to sub-therapeutic in recent months. Her two most recent INR’s and corresponding dosage changes are: (give example).
Assessment: She has no signs of external or internal bleeding. (give vital signs)
Recommendation: Do you want me to hold Coumadin for a couple of days and then restart? If so, what do you want her dosage to be?
Communication: Gave above orders to JUDY, patient’s daughter who stated she was removing the Coumadin from the patient’s med planner box now and putting the bottle of Medicine on top of the refrigerator so it wouldn’t be mixed up with normal meds.
All of these steps are important but detailed communication of orders is the most frequently missed step. It is also the step that could get you into serious trouble if the patient ends up in the hospital with a bleed to the brain. Documenting that you told the patient’s daughter is all well and good if she only has one. It is always best to document the name of the person you told and the time and date of the phone call. Details lend credibility. (And details are always easier to provide if you document contemporaneously with your work but that is a subject for another post.)
Sometimes, there is nobody reliable to instruct on changes. In that case, an additional skilled nurse visit should be ordered so the nurse can go to the house and remove the Coumadin herself. Since we know that unstable Coumadin patients are going to have a lot of unanticipated lab and orders, conservative scheduling with PRN orders for medication updates should accommodate the needs of the patient without breaking your budget.
Or, you can go back to my original advice and discontinue Coumadin on all of your patients but before you do that, let me explore some of the regulatory issues that may arise if you don’t follow physician orders. I seem to remember reading something about that somewhere
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