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…..
Patient Recruitment
February 12, 2012
Today, in Baton Rouge, someone was sentenced to prison for recruiting patients. While goofing off on the internet, I came across this story by Investigative Reporter Terri Langston published in the Houston Chronicle. Click on the image to read the full text which involves over 100M dollars in fraud and again, patient recruitment.
Now, color me clueless, but I really do not understand the difference between recruitment and marketing in the context that normal people use the terms in daily life. If you look up ‘patient recruitment’ you find tons of articles on how to recruit patients………. for clinical trials.
The dictionary defines recruit as, ‘to seek to enroll’ as students. This does not seem worthy of jail time either. Solicitation doesn’t seem all that horrible either. When I write a post and tell you to please call if you need help, wouldn’t that be soliciting your business?
So who better to consult than a health care lawyer.
Christopher Johnston has the distinction of knowing more people who have been or will go to jail than anyone else I know. (It is relevant that I have a very good friend on the SWAT team.) This is because he is one of the best lawyers for keeping healthcare providers out of jail or reducing their sentences. He also has to work with what he gets from clients and sometimes, well…… a couple of years is better than twenty. Chris’s success rate for clients who call him before they are in trouble is stellar.
He has a list of commandments to follow should you want to stay clear of any accusations of inappropriate marketing. Read them and share with your marketers. Chris is not a cheap lawyer and I am giving away his advice for free. Take it and run with it. Or don’t. Just remember that in this period of intense scrutiny, a reduction in your sentence may be the best anyone can do for you after you get caught.
- Do not bribe, harass, coerce, or intimidate any patient into selecting or changing agencies. (Julianne’s note: In reading Animal Husbandry Weekly, I gather it is okay to sell cattle per head. In reading the HEAT Task Force News page, I gather it is NOT okay to sell or buy referrals per head.)
- Do not allow any of your employees to bribe, harass, coerce or intimidate any patient into selecting or changing and agency. (Julianne’s note: What do you think a marketer will tell the investigators when they are caught? Do you think they will say their employer knew nothing about it or will they throw you under the bus?)
- Do not falsely advertise about any services, awards or credentials or anything that may mislead the public. (Julianne’s note: A nurse without a license is not a nurse for the purposes of home health. If you advertise nursing care, please send licensed nurses only.)
- You may certainly respond to inquiries about home health but DO NOT initiate the conversation. (Julianne’s admission of guilt: I might have to go to jail if I heard of someone who really needed home health but I would NOT – and do not – recommend specific agencies.)
- Do recommend that the patient contact his or her physician but do not recommend a physician to the patient. Under NO circumstances should you ever bring a patient to the physician or the physician to the patient’s home. (Julianne’s note: If you do not believe this happens, talk to your folks at MD offices. The waiting rooms are filled with aides bringing patients to MD offices.)
- Do not go into people’s homes or call them on the phone to tell them about the availability of home health. (Julianne’s note: We did not need a lawyer to tell us this, I hope and yet, I know of instances where it has happened.)
- Do not conduct marketing inservices in people’s homes. Stick to the physician’s office.
- Never, ever offer anything of value to anyone in an effort to select your agency or refer to your agency. (Julianne’s note: See the way Chris used both of the words, ‘never’ and ‘ever’ in his advice. I know from experience this means he is deadly serious about giving people cool stuff in return for being your patient or referring to your agency.)
Specifically excluded from these guidelines is community education. If you think about it, when providing support groups and speakers for community functions, you are generally not interacting with people who would meet the home health requirements for homebound status so there are no ‘patients’ involved.
The truth of the matter is that every time an agency gets closed down or someone goes to jail, it reduces my pool of potential clients. And remember, it is all about me.
And it is about you. My experience is that nurses who violate these guidelines typically are unaware that they exist. I am not completely innocent here. I have paid for drugs on occasion and also food. (Attention: if you are a federal agent or work for a contractor who has the authority to arrest fraudulent nurses, I haven’t been in the field since the 90’s. Surely there is a statute of limitations. If not, can I write my blog from prison?)
We can’t do this anymore. We absolutely must put safeguards in place to protect us from having to tell a client we are so sorry they have no meds or food but can’t anything about it. Because nurses are not wired to do that and we will end up in trouble if we don’t act preemptively. This means hooking up with your local food banks and indigent pharmacies and getting to know how they work before you need them. And when you have a few dollars to give away, donate them to the pharmacy or food bank.
And if you don’t have a formal compliance plan, contact me. If you have unwittingly participated in any of the above, contact Chris. We can help you. There I go again – soliciting business. It actually works. Sorry you can’t participate.
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.
