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.
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.
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.
Medicare 101
December 11, 2011
We have a lot of challenges in Home Health next year. No savior came to our rescue. Congress has absolutely no reason whatsoever to overlook home health when cutting the budget. They also have every reason in the world to come after home health for fraud and abuse and they have with a vengeance. They show no signs of stopping now and if you have been paying attention, nobody is safe. I have clients with as few as 100 patients undergoing a ZPIC audit and we know that the larger companies are not excused from scrutiny, either.
So before you get serious about implementing new programs and creating new ways to improve care while reducing costs, spend a little to make sure that you as a nurse or you as agency are building upon a sound foundation that protects you if you find yourself under scrutiny.
Take the Medicare Quiz and when you are through, you will see your results immediately. Let me know what you think of it.
Good Luck.
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Spelling Lesson
December 4, 2011
I received a request posted as a comment on a post written a while back called, ‘Documentation, Again!’ It reads as follows:
I wish you would follow up on this blog as it is connected to the number of visits that nurses are required to do on a daily basis. The “p” word – productivity is the game, as nurses will work off the clock to try not sink in case management and oasis issues. Somewhere in the world a daily productivity of 5.3 patients came around. However with the growth of paperwork and regulations, many nurses who are fighting to be there for their families in the evenings, work on paperwork out of fear. Home Health turnover is high because of this continued lie. You can’t tell nurses that they can completely finish 2 IAs and a visit, fully coding and doing 485 and 486 within 8 hours every time. I had a director who said that to do an IA you should stay in the home about 30 to 45 minutes then finish the paperwork later. Hum, check meds and do an assessment and ask oasis questions and go over plan of care in 45 minutes. How do we turn this lie around, without going to Labor Boards, etc. I believe that sometimes doing less turns out to be more money in the bank, if you focus on getting quality and consistency first, and building from there.
I am nothing if not accommodating, so please allow me to address this writers concerns directly.
Most people think that hell is spelled, H-E-L-L. It is not. Hell is spelled, Z-P-I-C. However, if you are lucky enough to avoid a ZPIC, rest assured in the knowledge that more audits are coming our way. The description sounds a lot like FMR pre-payment audits. Don’t forget about the new Medicaid RAC’s. Any way you look at it, you are likely to be scrutinized in the coming year or so by one or more payor sources who want their money back.
Two admits and a regular visit can be done but not every day. I couldn’t do it. I am not that good and have no desire to be.
As far as charting after you leave the home, that’s not really such a good idea. I think pretty much every nurse has been in McDonald’s or Starbucks charting when they realize they did not assess something. Maybe they started but then the office called to see if they could do another admit and they got distracted. A forgotten TUG score or temp are not really numbers you can just guestimate. Well, you can but documenting your guesses is really crossing the line.
The flip side of not being a slave to an arbitrary number is that productivity often drops when nurses are paid salary. It makes perfect sense on paper to have nurses on salary and ask them to maintain average and reasonable productivity standards but it just NEVER has worked.
I was in a client’s office about two and a half years ago reviewing clinical records when the Administrator, new to home health, asked me to look at productivity. She wasn’t sure but she thought that maybe the RN’s should be able to do more than one or two visits a day. I went about my business because obviously this home health newbie had her numbers confused. Before I left, I asked to look at logged visits. My next thought was that the person doing the logging was incredibly inept at clicking the mouse. Productivity was so absurdly low that I didn’t believe it until I started asking the nurses.
Long story short, she went to pay per visit but didn’t want to cut their pay so she paid them more per visit than I have ever seen any nurse get paid per visit. Sounds like a nut, doesn’t she?
If you think that, you would be wrongo. Her agency, rural, had a greater margin than almost all of my other clients. Her nurses suit up and show up and there is virtually no turn around unless someone is asked to leave. Case conferences are attended. Orders are written. Follow up is a way of life at that agency. Documentation is so good it bores me to tears and they are my only client who received a deficiency free survey this year. If they are chosen for any other audit, I will not lose a minute’s sleep over it.
So my first thought is whether or not the 5.3’ers are salaried or pay per visit. If they are paid per visit, are they making enough so that they can take care of their patients during working hours and be home with their families at a reasonable hour most nights?
I wonder how much those people who push for admissions to be submitted to the office within 8 hours are really losing. Do they know what is in the clinical records? Do they realize that unless nurses are blatantly committing fraud, the aggregate of errors is just about always in favor of Medicare? Those agencies who are brag about 3 and 4 days from admit to RAP are flirting with regulatory and fiancial disaster. Speed and accuracy rarely go hand in hand. The only time a nurse should not take a minute to reflect on her decision is when a patient isn’t breathing and they are turning blue. Even then……….. you got four minutes to consider the most likely cause.
But you asked me specific questions. First of all, I do not know where the 5.3 number comes from. I do remember CMS publishing something like that many, many years ago but it wouldn’t be accurate now. The next question is how to turn the lie around without a bunch of commotion, etc. I can help you there.
- Get all the information you can about the agency as a whole. This is not about you or the administrator/DON. It is about whether or not patient safety is protected at such a fast pace. Information that is relevant:
- Hospitalizations as reported on CMS along side your three biggest competitors.
- Average HHRG’s or payment if you can get it
- Other outcomes are not as useful but run them anyway. Choose your three biggest competitors and run the reports from Medicare.gov
- Number of call outs in the past 6 months from HR
- Do some research. This problem wasn’t created overnight and it will not be solved overnight. Two more weeks will not make a difference. Once a day, look at 10 charts for one specific thing. It will be real easy if you use point of care. Suggestions:
- Home Health Aide supervisory visits
- Weights recorded and reported as indicated
- Physician notification of out of range parameters
- Lab drawn timely and reported. If orders were issued as a result of the lab, are those documented and who was notified of them? (Check your Coumadin patients.)
- Are diabetics taught foot care every episode and is it done per ordered?
- Is pain noted on the visit sheet and if so, what was done about it?
- I am willing to bet you ten thousand dollars that if you grab 10 485’s and look at all the medications, you will find issues. Put them in the free Medscape interaction checker online or use iPhone/iPad app. Look only at the most critical ones listed first.
When you bring these numbers to the administrator, present them in a way that is impersonal and spread throughout the entire body of nurses. A lot of people want to know who did that, etc. with the goal being to fire the offender. When it is a little bit of everyone, it is more likely a systems or process problem. Explain why each area of compliance poses a threat to the agency.
Weights, lab and MD notification of out of range parameters are all deficiencies. Weights are tied to Congestive Heart Failure and that is the only diagnosis that has been shown to have an influence on home health hospitalizations. I hold Coumadin in the same esteem as I do Oxycontin bought off the street. It is dangerous and a malpractice lawyer’s dream. If the agency is not performing in these areas they are at risk for so many things, it would require the whole internet to put together a complete list.
Payment per episode should be close to $2,200.00 if you have a modest amount of therapy. It should be higher if a high percentage of your patients have therapy. If it is lower, one of two things is affecting it. The first is that the majority of your patients are old. I guess technically they are all mostly old but I am referring to length of time on service with the agency. The second reason may be because the nurses are underscoring in the OASIS dataset and time and education is required to do a complete and accurate assessment.
Now, if your administrator says that they are making a whole lot more than the average or if they say they will go ahead and write the supervisory visits or if they mistakenly believe that they are too large or too small to ever be of a concern to the feds, you need to take a hike. It is Christmas. Spend some time with your family. Do some baking. Start the New Year out in a new job. Can’t afford it? You can afford it more than you can afford to stay at an agency that cares more about arbitrary numbers than patient care. Trust me. I deal with this sort of stuff for a living.
Or have your administrator call me for an unbiased agency assessment by myself or a coworker. As a consultant, I have the freedom to walk away and not have to worry about a job.
