Thanks AdvanceMed!
May 1, 2012
Still working a ZPIC so I am short on time to keep you up to speed. Luckily, AdvanceMed has done most of my blogging for me tonight. On a spreadsheet from the Zone, there is a column for the reasons for denial. Below are some examples. Read your charts and see if maybe one or more claims could be denied for the same reason. If the answer is yes, it isn’t too late to do something about it. Call us!
The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The nurse continued to visit for observation and assessment when there were no acute changes in condition and no changes in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. There had been adequate time since start of care of XXXXX to have completed teaching in previous episodes. The medications: glimeperide, quinapril, atenol, and aspirin are indicated as new on the 485; however, there is no skilled service documented related to these medications.
The documentation provided does not support that skilled nurse visits are reasonable and necessary. The SN continued to visit for observation and assessment when there was no acute change in condition, no new orders, or change in the plan of care. There has been sufficient time since the start of care of xxxx to complete the teaching that was provided in this episode. The documentation provided does not support an exacerbation of the diagnoses as indicated per the 485. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation provided does not support an exacerbation of the diagnoses.
The skilled nurse continued to visit for observation and assessment of patient’s condition when there was no acute change in condition, and no new orders or change in the treatment plan. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation does not indicate that there is likelihood of a change in patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures. The records provided do not support an exacerbation of the diagnoses as noted on the 485, or a severity rating of 4 for the arthropathy diagnosis. There has been sufficient time since start of care date of xxxxx to complete teaching.
The documentation provided does not support that the skilled nurse visits are reasonable and necessary. Sufficient time has been allowed to accomplish teaching in previous episodes since the start of care date of xxxx. The nurse provided teaching related to a medication that was not new or changed. The nurse continued to provide observation and assessment when there were no new orders or change in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided.
The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The skilled nurse provided teaching on hypertension, fall precautions, range of motion exercises to help joint pain and relieve pressure on bony areas, low sodium diet, taking all meds as ordered, and ways to keep BP down. There has been sufficient time since start of care of xxxx in which to have completed this teaching.
So, there you have it. What you are looking at represents about 2M dollars in denials.
Questions?
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Thanks, HEALTHCAREfirst!
April 30, 2012
Bobby, Deanna and Meghan
Making it Happen at HEALTHCAREfirst
Now would be a good time to offer my sincerest gratitude to my hosts last week at the HEALTHCAREfirst Conference. I learned a lot of interesting things and met some really cool people. The most fascinating thing that I learned is where all the Healthcare First Data is stored. If you use Healthcare First software, you may not want to know the answer so I will leave that alone for now.
Although data storage is fascinating to be sure, I have never grown tired of hanging out with home health professionals. I learn more from y’all than anyone will ever learn from Haydel Consulting Services. Since I came home to a ZPIC requiring my attention, let me just briefly highlight some of the things I learned.
- The easiest way to protect yourself from Medical Review is to ensure that your zip code is not in Chicago.
- There are agencies – read carefully, Louisiana clients – that actually have average lengths of stay close to 30 days for Medicare patients.
- I don’t think there is a perfect place for the driving involved in home health. Did you know that there are agencies who pay for nurses to have chains put on their tires?
- Hospice providers may feel a little left out at times. I guess that is why they are receiving ADRs and other regulatory audits, at an alarming rate. PGBA, et al, did not want them to feel neglected.
- The Hard Rock Café in San Antonio is a great place to watch a parade during Fiesta.
More than ever, agencies are finding their revenue vulnerable as the result of extensive and robust (that’s a computer word) regulatory review by our Payor Source. HEALTHCAREfirst is stepping up to the plate to assist agencies in maintaining the integrity of their data. This is a good thing for the majority of providers who want to do more than simply survive in the upcoming years of uncertainty. But I caution you,HEALTHCAREfirst and all of their competitors sell software. You can push any button you want on the finest computer in the world and you won’t get nursing judgment or compassion to jump out of your machine.
Having said that, a cocktail of good solid data, strong leadership and intelligent, creative nurses is a plan for an agency that will enjoy financial and clinical outcomes long after this period of scrutiny settles .
So, I learned a lot and more importantly, I met some great people. It is really fun to meet a stranger who understands exactly what I do for a living and shares my love of the home health industry (inclusive of hospice, of course). My own family isn’t really sure what exactly I do for a living and I am not sure that anyone who isn’t on the playing field really knows how the game is played. So, it was fun meeting everyone and if I promised to call and you haven’t heard from me, please send an email. I have your card under a ZPIC letter so don’t take a chance on it getting lost!
Thanks to HEALTHCAREfirst and thanks to all of their clients who made San Antonio a really fun place to hang out for a few days last week.
Finding Mr. or Ms. Right
April 15, 2012
Too often, we settle on Mr. or Ms. Right Now when it comes to hiring nurses. This is especially of the Director of Nursing position because we are compelled to have a DON who meets requirements and to notify CMS and most states if the position is vacant and it should never be vacant for any length of time.
Ideally, most agencies have an RN already groomed for the position in their team leader positions. For these agencies, the burden then goes to hiring the right team leaders or whatever title your agency calls these alternate RN’s in the office.
Sadly, experience only goes so far in home health. It all depends on where the employee candidate was employed in the past. My suggestion is that when you hire any Registered Nurse for the office, you hire them with the awareness that they may be your director one day. After you determine that they meet al the paper qualifications, call them back in for a more in depth interview and ask some hard questions.
- What do you feel the biggest challenge to field nurses is at this time?
- If I told you that our average case mix weight I less than 1.0, what would concern you?
- If the average case mix weight was 1.9, would you be concerned?
- Describe your idea of quality management? What tasks do you feel are most important?
- In your opinion, which is more important? Getting paperwork in on time or getting it correct?
- Several nurses have threatened to quit because they believe they are not paid as much as your competitor pays their nurses. What do you do?
- Your patient has diabetes and arthritis. Which is the best code to use?
- What are three reasons that you might get in touch with the administrator over the weekend?
- Describe your computer skills. Do you use the computer only for work? Do you enjoy social websites? Do you use the computer a lot at home?
- What do you think a good average number of visits per episode should be?
There are no right or wrong answers and if a candidate is unfamiliar with the area discussed, it should not automatically disqualify them. If you are a legitimate agency, the response to number 7 is that the best code for the patient is the one that describes the patient’s condition. Number 8 will give you an idea of how comfortable the nurses is in taking responsibility.
The most important thing when hiring a nurse isn’t that she know all the answers. The important thing is that you are fully aware of where her shortcomings are and that the candidate is willing to learn. These questions will also give you an idea of the character and business sense of the potential candidate.
Agencies who use this level of scrutiny when filling all RN positions in the office are generally able to transition a current nurse into the DON position in the event of an sudden event. This has happened to my clients numerous times over the years. Losing a DON suddenly due to an accident or an abrupt termination is painful but it doesn’t have to be devastating if you have someone ready to assume the position.
It is so very difficult to work short handed. It is even more difficult to work when one or more of your RN’s is not able to perform. That’s when both clinical and financial health take a huge hit. Take the time to hire the right people. Trust me.
Thanks to All!
April 9, 2012
I had the most wonderful opportunity to show off what we all do for a living during the last week of March. Hugh, a reporter living in England wanted to find out how we Americans did home care and health care in general and ended up visiting with us and some of our clients. Before he arrived, he had time in Washington and visited with NAHC members and had the opportunity to stop by the Supreme Court while the historical hearings on Healthcare Reform were ongoing. Having never paid a physician bill or an insurance premium, he had to have been bewildered at all the commotion.
Upon arriving down south, he got to meet some of my colleagues, coworkers, and coworkers. Ray Banker, Demetrix Tolliver and Lorraine Wells all visited from local agencies. Jnon Griffin of Comfort Care in Alabama came to represent fans of the Red Tide. Poor dear. In case you think the South was overrepresented, keep in mind that Bobby Robertson from Healthcare First visited as well. His clients are spread out across the nation and he has unusually keen insights into our industry.
Ray Banker of Audubon Home Health made a big deal about having tickets to the hospital’s annual fund raiser which was featuring the 80′s band, Foreigner as the entertainment. He pointed out several times that there were no remaining tickets left so even if we wanted to go, we would not be able. I enjoyed the picture of Hugh with the band at the hotel bar later that evening more than a well balanced person should.
So, yes, I am grateful to all. My visitor learned more than he ever wanted to and we learned a lot from him as well. (As an aside, this man who has never paid a physician bill or health insurance premium comes from a country where only 8 cents of each dollar is spent on healthcare as opposed to 15 cents in the US.)
The fun part came later. Imagine if you were from another country where it is cold (by our standards) and rainy all the time. You fly into the states and hang out at the Supreme Court and NAHC and then arrive in the South and experience Southerners – US -for the first time.
Imagine that you have never seen a bayou, eaten a crawfish, touched an alligator or met a Katrina survivor. Thanks to Tory at Bayou Health Care, that is exactly what happened on Thursday. That’s a pretty big day by any standards.
The Katrina refugee was actually a patient with Medicare and one of those Medicare gold advantage plans. After falling off a ladder and breaking is pelvis, he was sent home at two am in what can only be described as frank, abject, maybe horrifying pain. Technically the pain only occurred when he moved but it was difficult to get him out of the car and into the bed without moving him. He is very lucky he is not married to me or he would still be in the car with his bottled water and his urinal. He was instructed to go to the MD within five days but couldn’t because his wife couldn’t handle the enormous task because of Multiple Sclerosis. Tori was working on it and a visit was scheduled to occur the day after we left – closer to 30 days after the fall.
Then we saw the alligators. I thought they were so friendly because they were cold but maybe not. Our guest noticed bullet hole in the head of one which completely dispels my illusion that the gators just liked me. Doesn’t that say volumes about my assessment skills?
Apparently there is a television show called Swamp People filmed in Pierre Part. We met several family members but ‘Troy’ was out getting some crawfish so we browsed the gas station in front of the Alligator fridge but none of us purchased a ‘Choot ‘em’ tee shirt. I feel sort of bad for the relatives of tourists bringing these home to family and friends in places where ‘Choot ‘em’ is not the phrase used to describe the act of discharging a weapon. They must think the Tee Shirts were discounted because of a screen print error.
I don’t eat crawfish unless it comes with a cocktail made from benadryl, solumedrol and epineprine which wasn’t on the menu at Landry’s but Mandy is a pro at teaching others how to eat crawfish. We are currently applying for Continuing Education credit for the course but so far have had a lot of documents thrown back at us for ‘clarification’. See photo. How could anyone need further clarification.
We stopped briefly at the Virgin Island – singular; not to be confused with the string of islands in the West Indies – to show Hugh snakes and turtles which are not common in England, apparently. He started getting a little anxious and wondered how he was going to explain away this 10 minute side trip as work. After I figured out that he was serious, I clued him in. This was home health. We don’t always stop to pet the gators but they were right there at the gas station anyway. Our Katrina victim and Medicare patient may have seen a bit extreme but all of our patients have unique histories and challenges. And in South Louisiana, there are only so many days when you actually want to get out of an air conditioned car so we took advantage after driving all day.
So our reporter will have many political twists and turns that affect our industry and be able to write with confidence about the National Association as they rallied – yet again – for a targeted approach to fraud and abuse. The grandeur of the US Supreme Court in the midst of three days of historical hearings on health care reform is decidedly noteworthy. But down the bayou, (or in the high rise, the mountains or the inner city) is where the patients can be found and wherever there are patients, you will find good nurses.
This is who we are – nurses taking care of people in their homes in the face of enormous challenges that have never been considered in Washington. Home health isn’t about politics or fraud and abuse. It is about finding a ride for a patient to get to the doctor. It’s about holding the hand of someone with a new diagnosis of cancer or trying to get the multi-pill jar patients seem to prefer sorted out. Its about teaching complicated medications to patients who really just want to get better and don’t care about anion gaps and insulin resistance. It is also about being a part of a community that may or may not include alligators and snakes, highrise buildings with unreliable elevators, icy mountain roads or too many narrow alleys roped off as crime scenes.
Seems to me that if a reporter from another continent can take the time out of his life to ride down the bayou visit patients, so can the politicians and lobbyists who believe they know what is best for the Katrina refugee who relocated after the storm and can’t get to the doctor in this family oriented community where he has no family. I wish the Supreme Court Justices would ask Tory what she thinks of the individual mandate. And I am very open to taking Kathleen Sebelius for a ride down the Bayou. If anyone sees her, tell her to give me a call.
Special thanks to my happiness engineer at WordPress. I tried to upgrade some services when my domain expired and what I wanted to do wasn’t possible. As it got later and later and my frustration grew, I emailed the support crew. Elizabeth, my happiness engineer didn’t just send me complicated instructions; she took care of the complicated domain mapping and such. I wish there were more happiness engineers in the world.
ADR Checklist
March 22, 2012
Prissy the Pit Bull available at no charge to review your records. We guarantee they will not be denied for lack of signature. We do not guarantee they will be paid.
Make no mistake that what I am about to say is shameless self promotion. The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency. This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.
Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews. More important than the actual content of the review is the attitude of the person doing the review. Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans. Your reviewer needs to be cognizant of the fact that any errors or omissions identified are tools to help cover their coworkers back and they need to be willing to help out their colleagues. If they can be ethically corrected, they should be. If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.
Here is what I look for:
- Orders signed and dated by physician.
- Face to face in all charts.
- Medications
- Diagnoses – note meds came first. Are there any meds for dx’s not listed.
- Frequency – does it correspond to the patients’ needs?
- Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
- Is teaching original and relevant?
- If re-teaching is present, is the reason why re-teaching was necessary explained?
- Does teaching require the skills of a nurse? It does not require the skills of a licensed nurse to tell a patient to take medications timely.
- ARE THERE ORDERS FOR THERAPY?
- Are therapy re-evals done on schedule?
- Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
- If subcutaneous injections are given, is there a reason why the patient cannot be taught?
- Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
- If the patient is seen for Management and Evaluation, is an RN performing the visit?
- If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
- Are patient and clinician signatures consistent throughout the record?
- Are there any hospital or MD reports that will support services?
- Does the clinical note contents support OASIS?
- Is the primary diagnosis the focus of care?
Notice again that two questions that are critical to payment are asked last. It is only after reading the entire episode that you can truly answer these questions.
There are so many other important elements in a chart that are required in order to reflect good clinical care. This is a payment review only. So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.
If you find egregious mistakes that cannot be ethically corrected, back out the claim. For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy. Print all paperwork and send it with the ADR. This will not prevent a denial but you won’t look stupid either. After that, find the therapist culprit and violate your work place violence policy.
I am very interested in knowing who is getting denied for what. Please email me privately if you have the goods.
And if you are not pleased with what you are finding, do not hesitate to call us.
