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.
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.
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.
