Payment Suspended for 78 Agencies
February 29, 2012
By now, everyone has heard of the very busy Dr. Jacques Roy who had more home health care patients than anyone in the entire united states and is accused of causing greater than 345M in false claims to be billed to Medicare.
Have you read the actual indictment, though? It names at least two RN’s as well. That really doesn’t bother me because I don’t count nurses who pay homeless people money as colleagues. I do so hope they lose their licenses.
What was tucked in at the bottom of the most recent article that came across my desk is that 78 home health care providers have apparently had their payments suspended pending the results of a full investigation.
This sounds extreme and it is because of the number of agencies that have payment suspended. However, these are not the first agencies who have had payment suspended because of ties to known or suspected physicians.
One client was assessed an overpayment of greater than 3M. This is small time compared to the 345M that makes headlines. Nevertheless, payment was suspended. Another agency with the same medical director likewise had their payment suspended. The second agency was not in a position to hire me due to the profoundly impaired cash flow.
Check your docs, folks. After these agencies had funds suspended I began researching the docs for all ZPIC clients. It is amazing what was found. The problem is that the state board of medicine doesn’t actually report on issues while they are still under investigation. In fact, the medical director referenced above was in jail for 8 months before the OIG added her to the exclusion list. The state board of medicine still lists the license as active and having no disciplinary history. (Jail doesn’t count, I suppose.)
I got the good stuff the way I get all the good stuff. I googled the docs. The press love photos of physicians being escorted out of buildings by men in uniforms. If there are handcuffs involved, it makes the first page.
If a physician has a restricted license, be sure that you are fully aware of the restrictions. Some physicians in recovery are not allowed to prescribe scheduled meds. Often a nurse will write all meds a patient is taking including scheduled meds from another physician. When the restricted doc signs the 485, he has just violated his license. I had never come up against that before and frankly, I do not know how these will fare during review. I am not hopeful, however.
For what it is worth, the client who was assessed the greater than 3M overpayment arranged to borrow the money from the bank so that Medicare could be paid back and the agency would be able to function until the appeals level of the audit. Medicare said, ‘thanks but we are not restoring your payments until after the entire investigation is complete.
In other words, a year or longer. That means that there are effectively 78 fewer agencies in Dallas this week.
On the bright side, you may get a really good deal on a licensed only agency but you will not be able to bill until you establish a new provider agreement with Medicare. Remember, if you purchase a provider and assume their provider agreement, you have assumed their debt to Medicare. You would think that would be obvious but it’s worth stating again.
So, check your docs. If you find out any good stuff about docs in my area (Louisiana, TX, Fl, AL), send me a discreet email at julianne@haydelcs.com so I can ensure my clients are not unwittingly involved with someone who will get their cash suspended.
Homebound Status
February 28, 2012
Last week, I posted about two patients who were driving but otherwise met the homebound criteria. Your responses impressed me. Above all, I was glad to see very few cut and dry answers and responses both sides of the fence were very convincing. The best part was that it occurred to me that if you put that much thought into the answers, then maybe I wasn’t insane after all.
In order to be completely objective about it, I had to return to Chapter 7 of the Medicare Benefits Manual and review these patients compared to Medicare’s definition of Homebound. Here’s the heart of the matter cut and pasted from the manual but divided into two parts:
- However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
- If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.
So, both patients meet the first criterion. It is a considerable and taxing effort to leave the home. In fact, I meet that criterion. I live on the third floor and at least twice I week I forget something upstairs.
One patient definitely does not meet the second criterion. Parking at the lake does is not how the patient receives healthcare or treatment and apparently this occurs ‘regularly’.
Based on the information I posted which is all I have, we cannot tell how often patient number two leaves the home.
The regs specifically address non-medical absences later in the section. Again, this is cut and pasted directly from the manual:
However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.
Now, go read it again. How often is occasional? What is meant by ‘relatively short duration’ and ‘infrequent’. Steven Wright illustrates relativity even better than Einstein when he says that everywhere is within walking distance if you have the time.
Since Medicare offers no further clarification of these definitions, we have no choice but to use the most conservative definitions and therefore, neither of these patients are confined to the home. I was so happy with my readers that none of you were happy with just stating that they weren’t homebound. Neither am I.
My suggestion to my client with patient number 1 was that they go out and assess him and explain to him why he should not be cooped up in a car for hours at a time. Homebound status is the least of my concerns at the point of referral. That would come in later after I assessed his risk of blood clots, ulcers, etc. from immobility. If he was willing, my client through diligent nursing care and therapy could restore his functionality to the point that it would be safe again in the future. If he was willing to comply with a treatment plan that included diet and weight loss, he could improve his life to a level he had not experienced in years. These things are not known prior to assessment. In fact, it is often the non-verbal language that clues us into the sincerity of the patients’ desire to comply with a care plan.
The report I received on the second patient is that he had dementia. Dementia as a diagnosis used on home health plans of care is very poorly defined in my opinion. Patients with early memory loss who end up on Namenda with no diagnosis of Alzheimer’s are often put into the broad category of ‘dementia’. Dementia can mean mild confusion at times or flat out psychosis. Furthermore, patients will often come out of the hospital with a diagnosis of Dementia that is carried over to the home health chart. Often times, quite sane people lose it considerably in the hospital due to drugs, illness, unfamiliar environment, etc. and get right in the head again once home. (I am re-reading this before posting. My first inclination was to find clinical terms to replace ‘lose it considerably’ and ‘get right in the head’ but those of you who live in other states will need to know these terms should you ever decide to work in the South.)
Pretty much everyone was on target with their responses. If the patient only has mild memory loss, he may be able to drive but will get lost and end up on Crack Alley negotiating deals for those pretty little rocks. If he is beyond mild dementia, the police or elderly protective need to be contacted immediately. My experience with Elderly Protective Services or whatever they are called in your community is that their scope of usefulness varies widely between communities so choose carefully.
Sadly, sometimes we are best suited to be the bad guy. The kindest thing to do may involve being the one who is willing to go toe to toe with a patient until they surrender their car keys. I mean that figuratively, by the way. There are laws against assaulting patients. We cannot take keys from patients or steal them but we can be the ones who tell the patient that we are by law obligated to report dangerous situations. We can notify the physician and even help him draft a letter to the Department of Motor Vehicles. Remember, the life you save may be your child’s. And even though it is no fun, it really is okay if the occasional patient doesn’t like you because truly caring for them means making them angry.
This is what upset me and why I asked the question of you. These two patients were referred to two separate clients in two different communities 200 miles apart. In both instances, other agencies had refused these patients due to the fact that they were driving.
I am not at all impressed with those agencies. Either they are much better than us in their assessment skills because they were able to make that determination without seeing the patient or they were not able to think critically and assess patients as individuals. In nursing, there are very few black and white decisions. Our patients are people and they are all unique and deserve consideration in these grey areas. Even if an admit isn’t forthcoming after the initial assessment, as nurses we should look at all the assessment data and determine what is best for the patient. If they turn out not to qualify for Medicare home health, perhaps we could find an alternative. And no. Medicare doesn’t pay for that but that doesn’t mean we don’t benefit from taking care of our elderly.
And so on……
A Slap in the Face
February 26, 2012
So last week I was reviewing clinical records at the office of one of my favorite clients. A patient had been admitted six months after having half of her foot removed. She had not walked since the surgery and was confined to the bed and the chair.
The first thing I noticed was that the description of the surgical wound sounded as though it were partially granulated instead of fully granulated. Six months is a long time but remember, amputations are not cosmetic surgery. It would not be unheard of to have a wound slow to heal in someone with circulation impaired to the extent that part of a foot needed to be removed.
I also questioned the diagnosis sequence and a couple of the OASIS questions in the functional domain.
Med orders on the 485 indicated that the patient was on both Dilaudid an Lortab but the chart only mentioned Lortab as being used for pain. My most humble opinion is that if pain is being managed with Lortab, the Dilaudid should come off the orders – especially after the first episode. The reason I feel this way is because if the patient had a sudden need for stronger pain relief, she may have other needs than Dilaudid that should be addressed immediately.
She had both therapy and nursing ordered. The nurse was quick to realize that the new orthopedic ‘boot’ designed to help her walk was causing the surgical wound to become red and irritated. Both the nurse and the therapist addressed this with the MD and the people who made the boot. I certainly cannot complain about that. But, after the boot was refitted properly, the nurse stayed in the home weekly even though therapists should be able to assess wounds.
In summary, I saw was that OASIS scoring left the agency with less payment than they were ethically entitled to for a very expensive patient and services being provided that may not have been required. And of course, there was the regulatory issue with duplicate pain meds.
While I was busy finding fault left and right, the most important thing almost escaped my attention.
After two episodes the patient who had part of their foot removed and had not walked in six months prior to admission was ambulating with a walker. The last nursing note state that the patient was in the kitchen upon arrival making coffee and using her assist device.
I am still not happy with the chart. My slap in the face comes from the fact that sometimes we forget that documentation is second to our real mission of providing care in the home. It is a very close second but failure to acknowledge what these incredible nurses and therapists did for the patient is the kind of attitude that deserves a slap in the face. If those of us who review charts on a regular basis cannot read between the lines and respect the care given to patients, we have no right to expect respect from field clinicians when we tell them all the things they did wrong.
Having said that, I have seen like a billion ADR’s and ZPIC denial letters but I have never seen one like the following. Please forward to me if you have.
Dear Administrator:
After careful review, our Medical Review department has determined that the cases mix weight determined by your OASIS data is in error. Specifically, a surgical wound and the functional domain were underscored resulting in a lower payment for this patient. In light of these egregious errors, Palmetto GBA (ZONE contractor or MAC of your choice) is adjusting your claim to reflect the correct diagnosis, surgical wound and functional status of your patient. This will affect the overall denial rate on your current edit.
As a provider, you have certain rights to appeal. Please see attachments on how to appeal a Medicare decision regarding payment.
Sincerely,
(Insert the name of your MAC or Zone Contractor)
PS please advise your nurse to take Dilaudid off the current med list and ask the patient to place it in a Ziplock bag with a large note that tells the patient to please call the nurse immediately should it be required in the future.
Driving Me Nuts!
February 20, 2012
So, people call me. They email me. I get the occasional comment on my blog. These are the ‘little things’ that make me useful to the home health community. I am aware of what is going on at the front lines of our industry. Usually, I can answer questions. Sometimes, I take a while and look things up. But sometimes, I get stumped. that’s when I turn to y’all.
In the past several weeks, I have had calls about two patients. Both are men. Both have been referred to clients. The question is the same for both of them. Do they meet the homebound status requirement?
Patient 1:
This is a man who drives a car. Not every day but at least weekly. It is a smaller economy car that gets ideal gas mileage. I sincerely hope that if this were all that you knew about the patient that you would declare him ineligible for services in a heart beat.
However, this gentleman weighs 400 pounds. He cannot get in the car by himself; nor can he get out of the car by himself. He just likes to drive and sit by the lake while his wife works. If he had to, he could drive up to the ER but then someone would have to come and get him out of the car. Fast food is available as are banks and dry cleaners who offer in car service. He cannot buy gas unless someone else pumps it for him, go to the MD’s office or outpatient therapy. In fact, he was at outpatient therapy for a while. His wife would get him in the car somehow and the therapy employees would get him out. At some point, it was deemed to dangerous for them to do that in the black asphalt parking lot.
I have a lot of issues with this patient besides homebound status. Blood clots seem a very real possibility. It is rumored that he pees in a jar. I am having a hard time imagining that he can do this without some spillage. So, now I have immobility, acidic urine and obesity threatening this patient. I get all that.
But, is he homebound?
Patient 2:
This patient has dementia with episodes of moderate confusion. Like the patient above they drive. They are not supposed to drive. Everyone knows that this is dangerous to the patient and to the community but no one has taken his keys away from him, yet.
Again, I have real issues with this. If the family is okay with him risking his life, that is up to them. I am not okay with his risking someone else’s life because they don’t want to take away the car keys. But it isn’t my feelings that we are assessing here.
I suggested that they approach the MD to get a medical restriction on his license and let him be the bad guy. But what should happen is again, not the question.
Is this patient homebound?
What do you think? Email me or comment below. I will share my thoughts after I hear some of yours.
Foot Assessment Tutorial
February 17, 2012
It is not my style to knock the advice given by the American Diabetic Association, Podiatrists, the Lower Extremity Amputation Prevention Program or all of those other so-called experts who teach foot exams. I certainly buy into their position that assessing feet is important for so many reasons but I find that their instructions are incomplete. In response, Haydel Consulting Services, LLC has stepped up to the plate to provide you with the missing pieces for a complete foot exam. Pay close attention. The skills you learn could save a limb or a life.
- Start with a foot encased in a shoe and sock. Take a look at the shoe to make sure it is appropriate for the patient and fits well. High heels, flip flops and all the other really cool kinds of shoes are not appropriate for many of our elderly patients. No matter how ugly the shoe is, do not criticize the patient’s choice of footwear if the shoes meet the above criteria.
- Untie the shoe. This may add some time to your visit but it will definitely make it easier to complete the following steps.
- Gently ease the shoe off the foot. Do not pull, tug or otherwise force the shoe off to prevent the foot from coming off with the shoe.
- Inch the sock down from the top towards the toes until the entire foot is visible. DO NOT ATTEMPT STEP 4 UNTIL STEPS 1 – 3 ARE COMPLETE.
- Attentively assess the foot according to the incomplete guidelines published by above referenced agencies. Notice how the nurse in this photo (Susie Soskin, RN) is at eye level with the foot. If you cannot get down to eye level, find someone who can or get the patient to lay down in the bed. If your knees are too old to bend down then chances are your vision is not good enough to assess feet from a distance.
- These are perfect feet. I know this because they belong to my son. I have bought hundreds of shoes for these size elevens. At the cash register, I have often been a bit overwhelmed at the cost of keeping him in shoes. After taking care of a few amputees, I am honored to have had the privilege to buy full pairs of shoes for him. I hope when I am dead and gone, he still has to pay for a full pair.
A high resolution copy of the above tutorial is available by clicking here. Please feel free to print it, share it or ignore it. And yes, I know the vast majority of us do take shoes and socks off every visit and look at diabetic feet. This is good but diabetics are not the only patients who benefit from foot assessments. Patients with heart failure or take diuretics will show signs of fluid build up in their feet, compromised circulation from cardiovascular or other disease can result in discoloration or stasis ulcers and injuries to the feet can be overlooked by any patient with loss of sensation or callused skin.
So, if this helps you to remember, all is well. If you don’t need reminding, kudos to you. If you think that one of your nurses or coworkers is not taking the time to do a complete foot assessment, draw a happy face on the bottom of the foot and see what shows up in the documentation:)
As always, questions and comments are welcome below or via email. As so on…..
