Dollars and Sense

In reviewing clinical records in the last few weeks at several different agencies, it seems the same mistakes regarding payment repeat themselves over and over again. Keep an eye out for these mistakes if you want to bill your ethical maximum payment:

1. ICD-9 Coding. Either the coding is good in an agency or nonexistent. If there is no one in your agency that is an expert coder, consider outsourcing your coding or investing in staff development. I saw tens of thousands of dollars lost in the past few weeks because of inaccurate coding. It pays to get your coding right.
2. Functional Limitations. The functional status of the patient does not contribute nearly as much to overall payment as clinical or service domains but the frequency at which questions are under-scored is enough to seriously compromise clinical and financial outcomes. It continues to be difficult to convince nurses that what a patient does independently is not the same as being able to complete a task safely. Safety is always the key to answering questions in the functional domain. Additionally, architectural barriers affect these responses – i.e. a patient could use the bathroom but because of stairs leading to the bathroom, it is inaccessible. In this case, questions regarding bathing and toileting should be answered accordingly.
3. Utilization. It seems that some agencies like to schedule patient weekly no matter what. Sometimes, they increase to twice a week. I know one agency who routinely schedules patient once every two weeks. None of these frequencies is bad. The problem is that they are assigned to patients without any regard to the patient’s need. By being conservative with visits, agencies can to increase frequencies for very high need patients without suffering financially.
4. Home Health Aide Visits. Home health aide visits are not a marketing tool. Some agencies tend to oversupply home health aides in order to gain a competitive advantage in their market. This may work for a small percentage of market share but in general it is a costly way to market. Agencies that are providing a high level of care and solid outcomes should not need to give away free care to snag the few remaining patients who will change agencies if they do not receive home health aide visits. Allowing your agency to be held hostage by patients and letting unqualified individuals determine your nursing care plan is never healthy for the agency.
5. Conversely, providing good care in home health actually means being present in the home. I always recommend being conservative. However, being cheap not only costs you money but also compromises patient care. If you want to perform at the level necessary to achieve good financial and clinical outcomes, you must budget for adequate utilization. If the OASIS data does not support the frequency that the patient needs, look at the data again. With few exceptions, the OASIS dataset will generate sufficient revenue to care for the patient.

None of this is new. However, ten years after the implementation of PPS, it is still prevalent in clinical records. The question isn’t what were we doing ten years ago but rather what will we be doing ten years in the future?

Your comments are always welcome below or you can email me personally.