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- Train staff based upon the most current guidelines not outdated belief systems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.
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.
