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Dance Lessons

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.

  1. 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. 
  2. 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.
  3. A letter will be sent to the agency for each claim that is under review. 
  4. You have 30 days to send the records to the FI.
  5. This information is also available through the DDE (billing) system and I strongly recommend that you rely on DDE as opposed to the mail.
  7. Once all of the letters have been sent, the ADR’s stop.  The edit is put on hold until your claims have been reviewed.
  8. Do not mistake this lull in activity as an indication that the MAC (FI) is through with you.
  9. The FI has 60 days to review the clinical records and make a determination about your agency.
  10. 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.)
  11. 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. 
  12. If you have a higher denial rate, the dance continues for another round.
  13. Education is provided by the MAC or FI during this time.  It usually consists of memos cut and pasted from the Medicare Benefits manual. 
  14. 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.

10 Comments Post a comment

  1. I am beginning to wonder why anyone in their right mind goes into home care, No other field seems to be this tormented. All areas of health care have hoops to jump through but it seems like they already assume that we are doing something wrong and are out to prove it. All we want to do is take care of patients and make a living doing it.

    January 13, 2012

    • It is a funny thing and to be honest, I am more on board with the present ADR situation than you might think. Here’s why. Everyday, millions of dollars in claims are billed to Medicare and they are paid. Just like that. Now, I ask you, would spend any money on something you never saw?

      So, I believe it is reasonable to look at selected claims periodically. The ZPICs on the other hand really get under my skin. Say you worked for your current agency for the past five years. Then one day your employer says that they have reviewed your work of last year and they didn’t think you did a good job so they demand that you pay all of the money back to them. That’s just wrong. If they paid you for a job, it was there responsibility to ensure they hired the right person and that they monitored your competence. There has been very little review at all since the inception of PPS until the last two years and now they say, they really don’t like the way you do things.

      My response to them is, well, nevermind…. this is a public forum.

      January 13, 2012
  2. RM #

    Recently danced 3 rounds in purgatory but saved from Hell. We learned a lot.

    January 13, 2012

    • Wow! I bet you did learn a lot. If you feel up to it (and I fully understand if your psychiatrist advises against ruminating over a a traumatic experience), please share with us what you learned. In my experience, whenever something like an audit happens, everyone wants to blame the nurses. And yes, the nurses do share the responsibility but it doesn’t stop there. Unless there are standards set from the senior level of managers, there will continue to be problems. If you hire the cheapest nurse you can find, you will get a cheap product. If the only education you deliver to the nurses is to increase reimbursement, every dollar that hits your bank account is at risk. If you are more concerned about the number of patients you have instead of the acuity of the patients, you will find yourself making a lot of copies.

      January 13, 2012
      • RM #

        Things we learned:
        Discharge when they are ready to be discharged
        Let therapy do their own opens and closes
        Do Not use words like “chronic”, “reviewed” or monitored.
        Fight the good fight to the end (got back some important money after talking to a judge)
        And just maybe living in California isn’t so wise after all.

        January 18, 2012

        • I get all of it except the advice to let therapy do their own opens and closes. Gimme a hint.

          California is beautiful but it has never been wise to live there. It costs a ton of money, everyone is too skinny and there seem to be cancer warnings everywhere you turn. I have to wonder if being reminded that you could get cancer so many times a day might actually lead to an increased incidence….

          January 18, 2012
          • RM #

            In the past we would put nursing on hold to let therapy do their thing and then send a nurse in to do the OASIS for the discharge visit. These visits were always denied for nursing. Now we do not try to save therapy from an OASIS.

            January 19, 2012

            • Ahhh……… got you.

              January 19, 2012
  3. ML #

    You are so right about learning to Dance that 1st dance. 1st impressions are sooooo important. If you have never responded to an ADR do not go this alone. GET HELP!!!! What you will pay will be nothing compared to what you could cause your company to payout if you get it wrong. This is a skill you don’t want to learn by trial and error.


    January 16, 2012

    • Thanks, Mona. The world is full of former home health owners who didn’t heed your advice and more will be joining their ranks. I think what isn’t understood is that while we charge a lot for ZPIC work, we mostly break even. It takes tons of man hours to get the charts out on time in a reasonable order and just check signatures. It isn’t rocket science but it is as serious as a heart attack.

      January 16, 2012

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