Difficult Decisions
February 8, 2012
Be honest with yourself. Have you ever held on to a patient longer than they technically qualified for home health services because there was nobody else to take care of them? Have you ever recertified a patient for diabetes because they had an isolated blood sugar of 302 after washing birthday cake down with coke? What about the patient who has achieved stability at rock bottom and the only alternative for the patient is a nursing home?
I can spot patients who do no longer meet Medicare coverage guidelines a mile away because of my superpowers. Also, I am not emotionally attached to your patients so it is easier for me to be objective.
These are the facts and I do not like them one little bit:
- Observation and assessment is a skill for only a short period of time (generally 3 weeks) unless there is documentation to support why the patient remains at increased risk. This means stuff like actual falls and changes to the plan of care. Headaches during allergy season that are controlled with Advil do not paint a picture of increased risk.
- Teaching is a covered skill. Re-teaching is only a skill if there is a documented reason why said re-teaching was indicated. Teaching is NOT a skill when it becomes apparent that the patient cannot or will not learn. This means that teaching an advanced Alzheimer’s patient new skills will not be deemed reasonable and necessary. It does not matter how hard you teach someone who is unable to learn.
- Homebound status is very poorly defined unless you work for someone with the authority to deny your claims. Document homebound status. If the patient meets homebound criteria three ways, document three times. Everyone is SOB with enough exertion.
- There is a space at the lower left corner of each 485 that reads, “Attending physician’s signature and date signed”. A Nurse Practitioner, physician assistant or love interest of a physician is not a physician. When you identify actual physicians, try to narrow your choice down to the one who actually attends to the patient’s need and obtain their signature. A signature is when somebody write their own name in their own handwriting or uses a secure electronic alternative. Don’t stop yet. Get the DATE. If you haven’t heard me rant about dates yet, it is because you haven’t been paying attention.
- Sadly, home health aide services do not qualify a patient for home health. In the event that you admit a patient who will likely require services indefinitely, that is the day you should begin searching for an alternative. Call relatives. Beg churches. If the patient has Medicaid, find waived services for the patient. Anticipate the day you will have to leave your patient alone in the house because there are no more skills to render.
It is heartbreaking to discharge some patients. Sometimes it helps if another nurse goes to do the dirty work. I have taken the discharge of patient in need of services not covered by Medicare harder than I ever took a death in all my critical care years. There’s nothing left to do for a patient at room temperature. Lonely elderly folks with vital signs are the ones who turn my heart to mush.
Knowing what constitutes skilled care going into the house will guide you in seeking alternatives to what feels like abandoning a patient in need. Remember, the folks who do ADR’s and ZPIC reviews do not know how sweet your patient is. They have not been seen how happy your patient was to share with you the cookies someone made for them at Christmas. They have not heard about the way music used to be played when it was good or held your patient’s hand when they lost a spouse. If you are a good nurse, a patient will touch your life as much as you touch theirs.
But, none of that sappiness, as real as it in our hearts will keep you out of trouble if you do not provide skilled services according to Medicare guidelines. When you fail to follow guidelines, you put at risk all of your patients, your employees or employers, their families and the agency’s stakeholders. Better just to start planning your exit strategy on admission, wouldn’t you think?
If you have any questions, please contact us or post below. If you want to hire Haydel Consulting Services to discharge your lonely patients, we will be glad to do so. Just take our regular hourly rate and multiply it by 72,761 and plan on a 50 hour minimum for discharge services.
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?
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.
THE Formula
December 30, 2011
The formula for making money in home health is simple. Take the number of patients you have and multiply it by the average payment and you can get a pretty good idea of what your revenue will be. I don’t think you need a degree in higher mathematics to figure that out. What I have trouble conveying to certain people is how the census influences the average revenue. The significant decrease in later episodes is enough to make a sane person think twice about holding onto patients who have met their goals but sanity doesn’t seem to be our strong point at times.
Luckily for me, Palmetto GBA has simplified the explanation for me. Here are some numbers that PGBA sent to one provider as an explanation for why they were undergoing a probe audit.
Length of Stay in Days
It would seem that this particular provider has an average length of stay close to a thousand days but Louisiana in general is closer to 400 (that is not a typo) and all PGBA states are just over the 200 mark. More than half of the agency’s patient are on service longer than 975 days.
Based upon these numbers, one would think that the provider who received this letter was paid a whole lot more than they should have been, right? After all, their patients were on service for twice as long as most Louisiana patients and three times as long as the average of all patients in the states that PGBA serves as a MAC. But, you would be wrong. Otherwise, I would not be writing this post. Here is the reality in dollars and cents.
Disbursement per Beneficiary
Suddenly the tops of the bars are a little closer together. The blue provider is only making slightly more per patient than agencies with a shorter length of stay and about 2K greater than all PGBA states.
So, if your strategy for increasing your census is to hold onto patients until they die, or quite possibly you die, you may want to re-visit that strategy. Everything else aside, the agency in blue is now burdened with the extra expense and stress of getting records ready for review by Palmetto GBA. In agencies with a large number of later episodes, the average HHRG will come up simply by discharging patients who are on service for longer than they need to be.
Keep one other thing in mind as you look at these numbers. The PPS system results in higher reimbursement for some occurrences in the later episodes offsetting this natural decline in payment. Patients who have surgical incisions in later episodes or a need for therapy actually pay much higher than the average. What this means is that patients who truly do require extra services because of a new diagnosis or event will generate the revenue required to take care of them.
The original formula still works but in order to succeed agencies need to understand how the numbers affect each other and aggressively pursue new admissions as the only way to build census. Holding onto patients apparently costs the agencies more than it does the payor source but it won’t stop them from coming after you if your numbers produce a graph such as this.
If you have received a copy of a similar letter from PGBA, I would very much like to see a copy of it. You can delete your agency information or you can be assured that I would never disclose your identity.
Don’t forget to register for the Food, Football and Fun event. Your nurses will come away with the tools your agency needs to survive the scrutiny that is apparently our fate this year.
Note: The blue numbers have altered insignificantly so that a provider’s actual data was not posted in a blog.
