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Less Than a Week…


My blog post today was supposed to be an essential piece regarding hearing loss in our patient population and what you can do to help your patients.  It will have to wait.  For now, just realize that lots of our patients don’t hear so well and it seems like you can’t do about it because Medicare doesn’t cover hearing aids. More about that later.  Email me if you admit a very hard of hearing patient. I do not intend to diminish the significance of hearing loss, but we aren’t voting on it next week.

Today, I’m going to do something I try very hard not to do.  With only a few days left until the election, I’m going to write a political post.  I try to avoid this because in my Pollyannaish heart, I believe we all want the same thing – a country that is safe, fair taxes and equal opportunities to make the American Dream come alive for each of us.  Obviously, we differ on how to get there.  And as far as unsolicited advice goes, I will limit it to my strong insistence that you vote. 

But I am spitting nails and losing my religion all at the same time this week because the president has accused pretty much the entire healthcare industry of colluding and conspiring to commit fraud.  He said that other countries stated that patients who died ‘with’ covid were not coded as Covid deaths but American doctors and hospitals just put Covid down for everything.

What does this all mean?  If the president knows what he is talking about and he does have an uncle who was a professor at MIT so he must know more than us, we have just been told:

  • Pretty much everyone in the healthcare industry deserves prison time. 
  • We apparently do not code as well as other countries.
  • We are all greedy and willing to compromise care for cash.

Healthcare professionals have gone from being heroes to criminals and for no purpose other than votes. Does the president not know how many registered voters work in healthcare?  This comes on the tail of insulting Dr. Fauci (or Tony as the president calls him).

The same people who would believe this are the same who believe Covid is a hoax but in the event they catch it, they can always self-inject bleach so why does it matter?

Unlike bleach recommendations and the prediction that warm weather will chase the virus away, this particular misinformation harms patients.  Patients who do not trust their physicians because they are criminals tend to be non-compliant. 

Can you imagine being told that a painful surgery or chemotherapy with a plethora of side effects is your best chance for living a long and healthy life by someone who merely wants to pay for a summer home?  Is there anyone in the world worse than a sleaze bucket who would lie about a diagnosis for a few extra dollars?   How about those patients on the ventilator in ICU’s?  Is all that expensive care really needed? 

What about the nurses, therapists, coders and billers who facilitate this fraud on the US government?  Fraud of this magnitude cannot be accomplished independent of the entire system.

I don’t often give advice on how to commit fraud, but I will offer one tidbit.  Do not have a lot of co-conspirators if you steal from the government.  It never works out. 

I may be wrong. My uncles never attended MIT. I am not on the cutting edge of bleached science. Doctors aren’t nice to me because they have to be and I don’t suffer if I disagree with the president. I am not important enough to be silenced by the white house.

I am not going to tell you how to vote but good information is required to make good decisions.  You decide how important it is to have the White House respect healthcare workers.  I know that I will do my best regardless of who is in office.  I also know that Covid isn’t a hoax treated with bleach.

For your Friday, enjoy two surgeons in the midst of the first surge of Covid singing Imagine on the front steps of the hospital. We all need a little hope.

A Busy Week in Washington


If you’ve been keeping up and I am not sure how you could avoid doing so, it’s been a busy week in politics. There was an IRS issue, the debates, and the announcement that the president and his wife had tested positive for Covid. Now he is in the hospital and his drug regimen suggests a very serious case of Covid but he and his physicians say that he’s doing fine. I have no opinion because I think the scope of Medical Practices differs a little for the president.

Now even more people in his immediate circle are known to be sick and regardless of your political views, this is not good news. I would not wish Covid on anyone and I wish the President and the first lady Godspeed in their recovery. Consider that wanting a new president is a lot different than wanting someone dead.

In our media fatigued nation, we were becoming sensitized to Covid after months of death tallies and counting cases. People are tired and broke and healthcare is still overwhelmed. After the president’s announcement, interest has peaked again making this a very good time to talk to your patients again about Covid, how it is spread and how to protect themselves. Be prepared to discuss the following information that is being widely disseminated on the ever present, 24 hour news channels and the always reliable internet.

  1. Testing does not cause the virus. The United States does not have more cases because we test more than other countries.
  2. Covid is more dangerous than the flu. More people die and there are serious lingering effects in a small number of patients including strokes and other neurological symptoms and permanent heart damage. This information can be given to patients without creating panic.
  3. Masks are effective at preventing the spread of Covid. The masks prevent the majority of droplets from entering the air so the people who do not know they have Covid are less likely to infect others. Masks are not a guarantee that you will not contract the virus and a mask does more to protect others than the one wearing it. Wearing a mask is a way of protecting the community. Your friends and neighbors and even strangers are protecting you when they wear a mask. Masks are at times unpleasant but they are such an easy way to be kind and who doesn’t want to be a little more kind.
  4. There are some activities and places that are safer than others. An outdoor porch with two people wearing a mask and sitting six feet apart is a low risk situation. Being in a small room with no masks in use creates a high risk situation if someone is infected with Covid. The problem is that we don’t always know who is infected. One study indicated that people are the most contagious the day or two before they show symptoms.
  5. Children do contract and spread the virus. The list of symptoms for children is similar to the list for adults but symptoms may be milder. Death has occurred but at a lower rate than adults. My question is about quarantine and isolation. If anyone has a known exposure to Covid, they should quarantine for 2 weeks. Any parents out there with small children who think that would be an easy task? I didn’t think so.

At this point in time, treatment is directed at symptoms. Information about specific medications should be referred to their physicians unless the medication is Hydroxychloroquine. In that case, your medical director might be called on to intervene. The first two medications given to the president are Remdisivir and Regeneron. Remdesivir has been given emergency approval because it has proven to reduce hospitalization time by a few days and Regeneron is experimental and the President received it following an FDA expanded use exception which provides that an experimental drug can be administered to a patient if the following conditions are met:

  • Patient has a serious disease or condition, or whose life is immediately threatened by their disease or condition.
  • There is no comparable or satisfactory alternative therapy to diagnose, monitor, or treat the disease or condition.
  • Patient enrollment in a clinical trial is not possible.
  • Potential patient benefit justifies the potential risks of treatment.
  • Providing the investigational medical product will not interfere with investigational trials that could support a medical product’s development or marketing approval for the treatment indication.

The third medication is run of the mill steroids like Solumedrol or Dexamethasone. They have been used in Covid in the past to treat inflammation. Because steroids seriously impair immune responses, these are usually given late in the disease to patients on ventilators.

In other words, there isn’t any one medication or treatment approved for the treatment of Covid so in general, the best advice is not to become infected.

Patients should be advised that the following is a list of symptoms for Covid (and other illnesses):

  • Fever or chills
  • Cough
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Muscle or body aches
  • Headache
  • New loss of taste or smell
  • Sore throat
  • Congestion or runny nose
  • Nausea or vomiting
  • Diarrhea

Because this looks a lot like the flu, there has never been a more important time to get a flu vaccine. That goes for visiting clinicians, too. Although there is no mandate for home health and hospice providers to offer annual flu shots, the cost of having visiting staff out sick for an extended period more than covers the minimal cost. Fun Fact: Medicare covers flu immunizations for hospice patients, too.

Your patients are at higher risk for serious illness and death from Covid due to age and underlying chronic conditions. Heart and lung disease and diabetes seem to be more prevalent in the underlying conditions category. Again, that can be conveyed to patients without causing panic. You know how to approach your patients because you have spent time with them. No need for police tape blocking off their homes.

Equally as important is educating non-homebound family members about the highly contagious nature of the virus. Teaching of family members is not covered in home health but it is not prohibited when another covered skill is rendered. Hospices are covered when teaching family members.

Should you have any questions, please email us so that we may refer you to someone who knows more like the CDC. Comments are always welcome.

A Long Summer


There are a lot of jokes about 2020 not being such a good year. For me, it is the year that I lost my mother at the tender age of 89 just weeks before her 90th birthday. To be honest, my math skills led me to believe she was 90 and on her way to her 91st birthday. Oh well.

Throughout this long summer while hanging out with Mama, I realized that we were living through history. Like the 1918 Spanish Flu, the Covid pandemic is an event that will continue to influence history for decades. I knew I should be writing about it but honestly, is there anything left to write? Maybe.

I lived through one aspect of Covid that isn’t getting as much attention as the number of cases and the mortality rate. My mother was ill since February and it had nothing to do with Covid. How she was treated and if she was treated had everything to do with Covid. In the end, I wonder if Covid will totally transform our healthcare industry.

My mother, always social, had very few visitors in the months prior to her death. I did not encourage visitors and when people asked if they could visit, I usually refused. I had two parents and my Dad, with Dementia, simply can’t remember to wear a mask correctly. It was uncomfortable for him and also, Mama. Covid would have been a death sentence for either of them. Even after it became clear that my mother was terminal, I would not have wished a Covid death on her. And who would have cared for her and my Dad if my son or I became sick?

Hiring help was similarly difficult. We got very lucky when an aide who is otherwise unemployed became available. She is sitting out the semester in college due to the pandemic and we are learning from the news that she may have made the very best decision. Agency help would have meant an aide that possibly went to different homes and it would be unfair to limit someone’s ability to work. Covid has changed the economic status of many Americans.

At times, I received a lot of encouragement to send Mama to the hospital. Each time her condition exacerbated, I called the local ERs and learned that nobody was allowed to stay with her in the Emergency room and if admitted, only one person who tested negative for Covid could stay with her. This person was not interchangeable. That meant my Dad who would forget rules about leaving the room would not be able to visit and either me or my son would not be able to see her.

Chances are we would have dropped her off at the ER like so much dry cleaning that got lost and we would have never seen her again. I could not do that and I had her written power of attorney for healthcare so it did not happen.

But there were friends and relatives who made life easier. I have a cousin who is a physician who visited. His approach to Mom’s care was like mine – as long as something was not painful or invasive, Mama got it. No extensive treatment or ‘heroics’ (as she called them) were attempted. If Mama were around or if she is reading this blog post, she would tell me to add to it that there is nothing heroic about shoving a tube down the throat of a senior octogenarian simply to prolong a heartbeat. And Mama is always right.

A cousin who is a nurse along with her daughter provided the very best palliative care – chocolate peanut butter cookies from the Snoop Dogg and Martha Stewart collaboration cookbook aptly named From Crook to Cook.

Another local cousin dropped off meals. It was gourmet meals on wheels. Like kids playing a joke on neighbors, the doorbell would ring and nobody would be at the door but when I would look down, there was dinner. There are no words to express how grateful we were for the care packages.

Cards were also delightful especially to mother. The beauty of cards is that they can be set aside when appropriate and read repeatedly when someone is awake.

I tell you all of this because unless a treatment is found for Covid very soon, everyone will have a friend or relative with Covid or another illness that prevents visits. You can still let them know that you care. Snoop, Martha and Cousin Tillie would want you to find a way to bring chocolate comfort.

Still, I would have hired help earlier had it not been for Covid. I would have maybe, just maybe, taken Mom to the hospital when she first had a GI bleed just to see if the problem was easily correctable. I would have had hospice come in earlier. As it was, I had access to a hospice client who gives excellent care and they were on call for me whether they knew it or not. Thanks Audubon.

Humana saved a ton of money on my mother without changing the outcome of her illness. I realize this a luxury because not everyone can take a break from life to provide total care to an elderly patient but I wonder how many people are not accessing healthcare because of the pandemic. Are outcomes in general significantly changed?

But that’s just my story of how Mama saw a return on investment on my nursing school tuition.

Covid has affected every aspect of our lives from how we work and shop to how we educate our children, socialize and even experience illnesses. Politics has played an inappropriate role in determining our response to Covid.

I hope you’re keeping some sort of record. 102 years after the Spanish Flu, it is the personal accounts of the patients and the healthcare workers, and even the San Francisco Anti-Mask league of 1919 that tell the story of the Spanish flu. Some numbers are just too high to comprehend.

If you are keeping some sort of record, please consider sharing all or part of it with us. You can email me here.

COVID-19 for Visiting Nurses

How should home health and hospice visiting employees address Covid19 and protect staff and patients?

Read more

Company 1


Take heed

Suzanne May, age 61, served as the administrator of a hospice referred to by the Feds as Company 1 for more than a decade She was a both a registered nurse and a certified hospice administrator. She signed a plea deal admitting to fraud on December 3, 2019 and now faces five years in prison followed by three years supervised release, a $250,000.00 fine and to top it off, a $100.00 special assessment. Hopefully, her lawyer can negotiate a deal where the special assessment is knocked off of the overall penalties.

Altering Legal Documents

To keep it short and simple unlike the official documents, Ms. May has admitted to:

  1. Using white-out on a Certificate of Terminal Illness. If you can’t figure out why that might be a problem, it’s best that you resign now.
  2. Adding dates to Notices of Election after the clinical records were requested from Medicare. I do not know how Federal Investigators knew when the dates were added.
  3. Ms. May relieved some patients of the burden of initialing forms by adding their dated initials to forms. The Feds are alleging that it is not possible to sign and date documents after death.

In an impressive display of organizational skills, Company 1 employees, led by Ms. May, kept a log of all changes made to the documents after the request for records was received.

This audit, performed in 2017, followed a 2015 audit in which close to $400,000 was returned to Medicare. As a certified hospice administrator Ms. May knew what was required of the hospice in order to be paid. And, to her credit, she made sure every detail was complete but only after her clinical records were requested by Medicare. Timing is everything.

Look Again

This post teaches you how to go to jail. Free meals, a warm place to sleep and a break from your needy relatives may be your ticket to jolly holidays. Surely the worst prison food is better than fruit cake and squash casserole.

In no way am I condoning the actions of Ms. May. I also recognize that the criteria for payment is sometimes preposterous. Claims for reasonable and necessary care provided to eligible beneficiaries are denied payment every day but that is a subject for another post.

In this case no patients were harmed as a result of Ms. May’s actions. Nobody dies from a date added to a document after they die. If jail is your ideal vacation, this seems to be the way to go if you don’t want any patients to be hurt along the way.

If you wish to remain home with your loved ones, I assure you that no matter how tempting it is to add a date to a form because the patient didn’t, and you know the correct date and personally witnessed the patient sign the form, it isn’t worth it. When a physician doesn’t date his or her signature and you know when the orders were signed, adding the date seems more like a courtesy than a felony but you would be wrong in making that assumption.

If this sort of behavior was evident on a state survey and a plan of correction to the state was required, it would probably include an educational piece like, ‘The DON will hold an inservice to teach the nurses things that they already know but didn’t do.’

If you are finding these problems during clinical record and billing review despite teaching the nurses repeatedly it’s time to try something new.

Cut your employees some slack. Home health and hospice nurses who provide excellent care to your patients are worth a little extra time. Review their paperwork with them as it arrives at the agency – which usually occurs before the time (and possibly the patient) has passed to get an ethically dated signature. Help them develop habits.

On the other hand, if a nurse blatantly commits fraud, investigate first and then terminate them. You are also obligated to report them to Medicare and their State Board. A good orientation will ensure they know the rules. Protect your nurses and the agency by providing a complete orientation including compliance. 

Do not bill (or alternatively, pay back the money) if you have found out that a nurse was taking shortcuts. It is painful to take the right steps but not as painful as the quarter million fine Ms. May will pay (plus the assessment fee).

If you are a visiting nurse, you know the rules. You know what to do and mostly you get it right but it only takes a couple of bad care plans or notices of election to cost an agency tens of thousands of dollars.

More concerning to me is the probability that some nurses are encouraged to ‘do what it takes’ to get billing out the door. Without using the words, ‘go commit fraud’, some employers leave employees feeling like their jobs are on the line if they hold up billing. If you feel that the only way to keep your job is to fill in the blanks omitted by a patient or a physician, I guarantee that unemployment is a better option.

Everything else aside, ask how Medicare knew the documents were altered by Ms. May and friends after the patient died. The Feds are not psychic. They did not have a seance summoning J. Edgar Hoover who revealed the exact time that dates were placed on documents. They obviously knew something that was solid enough for them to request 100 charts.

I’m willing to bet that Company 1 is not the real name of the hospice and that this story has just begun. Until we find out more, do yourself and your patients a favor and do things the right way. If you are preoccupied with compiling charts for an audit, care to your patients will be compromised. I’ve seen it too many times.

As always, your comments are welcome or you can email your thoughts.

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