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More on Medicare Fraud and Abuse

Apparently, HHS Secretary Kathleen Sebelius ad Eric Holder, the US Attorney General had a ‘summit’ regarding Medicare Fraud and Abuse.  You can read the whole report here.

At the summit, Secretary Sebelius announced that starting July 1, HHS will begin using innovative predictive modeling technology to identify fraudulent Medicare claims on a nationwide basis, and stop claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made.

I think this is a good idea.  There are patterns of abuse that repeat themselves in almost every fraudulent agency and it is easy to write programs that identify them.   In one of my ZPIC audits that I am working, there is a clear and distinct pattern of low utilization combined with very long lengths of stay.  This is not to say that all patients had old start of care dates.  Many of the patients have been admitted and discharged several times over. The numbers you review regarding length of stay based on individual admissions may be lower than what the feds calculate based on the entire claims history of the patient.

Another pattern that shows up repeatedly is high therapy use.  I have two excellent clients that have inordinately high therapy use but I don’t worry about them.  Many of the patients are total knee replacements or other ortho surgery and after six to nine visits, the patients are discharged.  But if all of your therapy patients are being seen for ‘gait instability’ related to chronic illnesses and all of them receive 14 or more therapy visits, expect to find yourself on the ‘naughty list’.

Overuse of any one diagnosis code alerts the feds to potential fraud.  Not everyone with impaired vision has a diagnosis that can be supported with physician documentation.  And most who do will have other claims in the Medicare system that supports the diagnosis such as ophthalmologist claims and pharmacy claims for eye medications.  The feds access to information is unmatched.  If they use it properly, no one who is even an inch over the line will be spared.

What I find particularly sad is that when I look at agencies’ clinical records, I see some practices that are common, ineffective and are certain to place the agency on a watch list somewhere.  For instance, a nurse will have been taught, and in very good faith believes that if a patient has diabetes, it should always be primary because it pays more.  And then she goes to work for one of my clients and it may take a while before the diagnosis problem is discovered.  And yet, these same agencies are continually leaving money on the table by not assessing a patient accurately.  They routinely increase payment inappropriately by a few dollars while ignoring the hundreds of dollars per day they leave on the table.

Before I take on any client, I look at the CMS reported outcomes.  In particular, I look at the hospitalization rate calculated by CMS. There may be various reasons why different agencies send their patients to the hospital but when it comes to extraordinarily high hospitalization rates (over fifty percent), there is only one reason.  The agency does not discharge patients to the community.  In other words, most of the patients who are discharged from the agency are discharged because they are in the hospital over the end of the episode and the discharge is because the agency has not been able to follow OASIS requirements resulting in a discharge and readmit.  If you think the Feds don’t know this, consider that I know it and I have a fraction of one percent of the data the feds have available to them.

So, look at your numbers.  Look for patterns.  If you are concerned that the new data mining implemented in July may pick up on some unusual patterns in your agency call me.  I can be reached at 225.253.4876 or you can always email me.  I will find your patterns, deconstruct them and help you reconstruct your care so that you make as much money as you ethically can without creating patterns that even remotely resemble anything less than one hundred percent compliant with Medicare payment guidelines.

8 Comments Post a comment

  1. I’m so glad to hear this! I’m a surveyor and see what I consider to be lots of records and visits where there is just no evidence that this care is reasonable and necessary. I call them social visits with vital signs and it is maddening to observe.
    I’m glad Medicare is at least thinking about ways to limit out tax dollars to care that is necessary and to care that prevents hospitalization. Thanks for the report.

    July 14, 2011

    • I love that term! ‘Social Visits with Vital Signs!’ If agencies don’t want to comply, they should at least think about catering visits.

      July 14, 2011
  2. gail #

    I never did understand the “pay and chase” philosophy. It makes no sense. As noted, if the submission to Medicare doesn’t meet certain criteria, just don’t pay it in the first place. Go after the real “crooks” and get the real fraudulent wasters of Medicare funds so those of us who do the right thing and follow the rules can just go about our business of trying to take care of those who need us. And while I’m on the subject of “those who need us” I would like to add that many of our patients who are elderly, forgetful, have no willing or capable caregiver would deteriorate and/or end up in a nursing home without us. What good would that be? I do agree that some documentation by the nurse looks like a “social visit with vital signs” (I like that too) but they do so much more when you question them about what is going on with the patient. They just MUST learn to document what they really do and give themselves some credit. I hear this all the time, “I’m just in such a hurry to get it all done and have a life.” Well, you won’t have a job if you don’t make some time to document correctly!!!

    July 15, 2011

    • One of the most difficult things for me to teach is eligibility for Medicare Home Health benefits because my heart is not in it. I have so many clients tell me that if it weren’t for them, the patient would have nobody checking in on them and the patient would end up in a nursing home. I hate that. And yet, Medicare does NOT cover chronic care in home health. It has never been meant as a substitute for nursing homes. Having said that, a patient is eligible for as many contiguous episodes as is required to provide skilled care that the patient needs to address his or her physical and mental condition. The problem, just as you state, is that nurses can tell you more than they write down. I liken it to playing ‘House’ as on House MD which, in case you don’t watch, is loosed based on Sherlock Holmes. In home health, we have the unique opportunity to see all of the factors that challenge patients within their own environment. We should be looking for ways to justify skilled care like a forensic scientist examining clues. Orders (legitimate) orders usually show an ongoing need for skilled services. Medication checks where the potential for errors are found is always a good way to justify a visit. I am always appalled when I see a nurse write that lungs are clear to auscultation repeatedly – especially in South Louisiana, mold capital of the world. But do we really ‘listen’ and address findings in writing?

      The key to remember is that the people who look at our charts are used to so many people upcoding, keeping patients on service longer than needed, and otherwise spending millions of Medicare dollars that shouldn’t have been spent. They are expecting you to be a criminal. They get excited when they find that you have done something wrong. They are blissfully content when they can deny a lot of money. If we want to disappoint those who think we are complete idiots who have nothing better to do than steal from Medicare, we have to document. Plain and simple.

      July 17, 2011
  3. Caretha Thomas #

    There is a better term that comes to my mind on this
    issue…”Drive By Nursing”. It has really gotten out
    of hands. It is very hard to find a “good” nurse
    these days…

    July 16, 2011

    • I guess drive-by nursing is better than ‘drive through’ but you have a point. Home health and nursing homes get the very best nurses in the industry and the very worst. You have to love elderly people to do your job well. If all a nurse wants is an easy schedule or lots of unsupervised time, he or she will not serve our patients well.

      I am always good with teaching nurses how to assess according to OASIS guidelines and get the ethical maximum out of PPS payments. That stuff is hard to learn. But I am never okay with an inattentive approach to nursing or nurses who do exactly what they need to do and no more. Creativity is as much a part of nursing as science is. We need nurses willing to really figure out a problem in the way that helps the patient regardless of what is written in a book somewhere and then transcribed on a visit note.

      A few months ago, I was at an agency. The skilled nurse had made a visit in the morning and the patient was out of a schedule II medication. The nurse called the doctor and sent over a list all of his other medications to ensure that the doctor had all the information he needed to write for a refill or choose another drug. They do that for every MD communication. Somehow, the patient got the prescription but he was at dialysis later. Since the medication was already late and the patient was in significant pain, another aide drove by the dialysis center and got the prescription from the patient and dropped it off at the agency where the nurses could add it to the med profile and then drove it to the pharmacy. The case manager then called the dialysis center and left a message for the patient when it would be ready. The patient, alas, had to be taken to and from dialysis by medical transportation and there was no stopping at the drug store. So. the nurse called the doctor, got a PRN visit order and picked up the medication on her way to the patient’s house.

      I was just an innocent bystander reading charts when all of this was happening. It slowed a couple of nurses down. It made for extra work. There really is no requirement that nurses and other staff drive all over creation to help a patient in pain and schedule extra visits. But they did. And the next day, I read about it in the chart. All of it. Wow.

      July 17, 2011
  4. Susan #

    I may quote you 🙂

    July 16, 2011
  5. Danny J Crudo Pharm.D., M.S. #

    All great idea’s concerning zpic’s. I would have to say that based on my limited involvement with the zpics ( one home health care agnecy and one dme respiratory company) you must first have prudent reserve to last the non payment period. Both of the companies i worked with were very clean and compliant, one was on full edit at the NSC and the other was select edit, primarily therapy visits over 14 final billing edit. The full edit took 4 months and 400 chart submissions but the edit was lifted. that company had the funds to last the audit. The second company is still going thrue it but may not make it. They have an ortho that has a protocol for is knees 3 w 5 for therapy and final billing is being audited. needless to say the company has had to compleatly overhaul operations to sustain viability thrue this and it is not over yet. I have spoken to many companies that just threw in the towel when the zpic started at them because they simply ran out of money. I have had to learn more than I ever wanted to about this new and very unique integrity program. i could remark all night about this, but i did want to repmark to all those that are trying to stay aware, the prudent reserve that medicare requires all providers to have is what the zpics will reference when asked about provider closings due to audit.

    danny j crudo pharm.d, m.s. regulatory affairs specialist / medicare program integrity

    July 26, 2011

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