I see a lot of denials in my job. Some (actually a lot) are legitimate because the agency hasn’t complied with one or more regulations. I have also seen an alarming rate of denials that cause me to question the competence of those performing the reviews.
Last week I received a copy of a denial. It was actually the second denial on the same claim. Palmetto GBA originally denied the claim as they did not think that the Alzheimer’s patient confined to a wheelchair was homebound. My client appealed to Maximus who agreed that the patient was in fact, confined to the home but then denied the claim because there was no documentation of the face to face encounter. The reason my client did not send the documentation is because the episode in question was the second episode and the face to face encounter occurred prior to the first episode.
I am also seeing claims denied because of physician signatures. In some states, my own included, the signature requirement in the minimum standards reads that if the agency documents when the orders were received by the agency, that will suffice as evidence that orders were received timely according to state minimum standards.
The state does not pay your Medicare Claims.
Medicare requires that the physician both sign and DATE his or her signature. Failure to do so will result in a denial.
Statutory denials are like free spins on the slot machine for the folks who review ADR’s and other claims. A statutory denial means that the patient was somehow not eligible for services and therefore, nothing is covered. Compare that to a denial because the reviewer did not think that two of the visits were covered. If the total number of visits was greater than 6, then the two non-covered visits will not result in a loss to the agency. If an ICD-9 code is not supported, the payment will be downcoded usually costing the agency a couple of hundred dollars. But if the patient is not homebound, or there is a problem with the physician, or the orders are not signed, the claim is denied in its entirety and no further effort is required by the person doing the review.
Now, if it were me and y’all can thank your higher power it isn’t, I would go for the statutory denials every time. (And I could find them, too.) These are also the easiest to prevent.
- Everyone in the agency should be aware of the signature requirement. The primary responsibility should lie with the first person who sees the orders whether it is the marketer or the person receiving the mail. However, nobody should see an undated signature without bringing it to the Director’s attention.
- Be obnoxious about dates. Buy some file folder labels and print, ‘Please sign and DATE your signature’ at the bottom of every order. Use red ink. Make it interesting and noticeable. Add a note about dating signatures to your fax cover sheet used for orders.
- Because marketing staff often have more exciting things to discuss, make badges that read: I need a date. That will spark some lively conversations.
- With every ADR that is submitted to your MAC, include the description of homebound status as found in the Medicare Benefits Manual.
- After the patient’s initial episode, ensure that the face to face encounter is included in the summary. That leads me to;
- Write a summary. If your agency is not writing summaries for each episode, begin writing them now. For ADR’s there is nothing wrong about documenting after the fact as long as the documentation is dated on the day that you wrote it.
- If you find an egregious error that cannot be ethically corrected, cancel the claim and send documentation along with your ADR. This won’t affect the outcome but it is the classy thing to do. It also shows that you do know how to recognize errors. Please note that some errors can be corrected ethically. Do not be too hasty in cancelling claims.
- If at all possible, have someone who has not been involved with the patient review the documentation you intend to submit. It is too easy to read between the lines when you know about the patient. The holes are not glaring to you. If you have a branch or if there is an another agency owned by the same organization, trade off ADR’s. If you do not have a sister agency or anyone in your organization, consider using a professional consulting service. I can recommend a good one if you need one.
- Write a cover letter if there are any discrepancies in your documentation. For instance, you may have a very weak patient who progressed to her highest level of functioning with therapy in a prior episode. Note this so the chart does not look as though you have a patient in need of therapy but failed to provide it. (Yes, the reviewer should be able to look at past claims but they should also know homebound status and when the face to face encounter occurs as well.)
- Share your ADR results with your staff. It is so much easier to learn from the errors of others. Too often, agencies don’t want word to get out on the street that they have received a ton of ADR’s. Get over it. ADR’s are being sent out at a rate that might very well save the United States Postal System from financial ruin.
We are always interested in hearing about those strange and somewhat inappropriate denials. Please share with us if you have one that we might teach us all a little something about getting paid. After all, it doesn’t matter how much congress reduces the home health payment if you are never paid.
And as always, we are available to help with ADR’s. We read clinical records as though payment is coming from our own pockets (because it is!) and do our best to get you paid. Mind you, we can only work with what we are given. So, write those summaries and get signatures dated.
And I’m one of the 1% that refuses to participate in social networking sites of any kind, so sorry, can’t like you
I appreciate your compliment and fully support your decision not to participate in Social Networking sites. Kudos to you.
Take your claims to the Administrative Law Judge and let them make the determinations….. You’ll be surprised at the outcome…
First of all, Mike, I long for the days when getting a claim paid by the ALJ was a rubber stamp deal. The judges are not nearly as kind as they have been in the past. Furthermore, the Medicare Appeals Council has recently overturned a decision by an ALJ (not so unusual) but here’s the kicker…….. Nobody requested the council to review it.
Before a claim even gets before an ALJ, there are various levels of appeals depending on who denied it. For a basic ADR, it can take 6 – 9 months. For my ZPIC clients it is taking closer to two years to make the rounds through the appeals. There are two very important factors here. One is that if the claim is denied and overturned at at a later level of appeal, it will be too late to go back and recalculate your denial rate. This may not be a big deal if it was the only claim denied but if it tipped you over into territory where you have an extended period of review, it can cause a lot of headache. Secondly, my clients can go without payment for an isolated claim or two but for the most part they are small. Think about the math. If you have 200 patients, you bill half of those each month. If your average claim is 2.000.00, that means you are billing 200,000.00 per month. At a modest 6 percent margin, that is good money for the owners equaling about 12k per month. I can get by on that. Ideally it is higher but small agencies have their own set of financial woes. So, if one claim is denied, it pinches a little. If two are denied, then the organization’s income just dropped by 33 percent. That would never happen unless college tuition was due for a kid, a large unexpected tax bill came in the mail and one of your doctor’s is in the hospital and the ICU witch won’t let you in to get orders signed so you can’t bill. Now, you are at the bank pleading for a short term loan to cover payroll and paying interest on the money that should have been yours to begin with. It is so much easier to put the effort in up front.
But if you are large and bill hundreds of claims a week, you are right. I do find it rather irritating that the number of ADR’s is rather static between agencies. I have a large client with over 800 patients in a single provider. If they got 30 ADR’s, it would not keep anyone awake. My smallest client is about 130 patients.
By the way, the same arbitrary numbers are used for hospices who have a much lower census. If you have an in at CMS, tell them I do not approve.
Thanks. Your comments are always appreciated.
Good Stuff. I’m learning every day. Thanks Julianne.
My wife is a social worker and often tells me stories like this where getting paid is the toughest part of the whole patient care process.
It should not be that way.
With the movement towards electronic records and technology to support electronic signatures, I have begun learning about regulations/laws/precedents to help folks like yourself get paid. It seems to boil down to proving the identity of the signer and making sure an order/document has not changed since the signature was applied.
I may be in over my head, but could you comment on current LA laws surrounding electronic and digital signatures? Our company has begun work with a few TN healthcare providers in hopes to streamline their signing processes online, no software, no hardware, to help people get paid quicker with less confusion/deliberation.
I would be interested in speaking with you about such developments and get your opinion on the movement towards electronic records.
Andy, you are welcome to call me – fridays are usually slow for me. Both Louisiana and the Feds accept electronic signatures. However, in home health in Louisiana, the patient must sign during the actual visit. Setting up elderly Medicare patients with electronic signatures is a nightmare – if they can’t remember their meds, how are they going to remember their signature specific password from week to week? So, the visits must be signed.
My thought about signatures is that there is always a way to get around them. I can create an electronic signature right now with your name on it and unless someone thought to ask you, I could electronically sign all sorts of documents with your name. The ultimate defense against an accusation of fraud would be to have GPS tracking devices that showed where a nurse was at all times. It would also help agencies identify rogue nurses when a problem was small and isolated instead of hearing six months later that a nurse skipped visits and turned in paperwork. In a case like that, the only safe response is to back out every visit he or she made that cannot be independently verified. Call me sometime. Again, Fridays are preferable.
You are exactly right about elderly patients…assisting them to “remember” a pin is a little illogical.
Pertaining to your electronic signature reply, I completely understand. You could take my name and create an “electronic” signature. The differences between electronic signatures and digital signatures are subtle, but the technology behind digital signatures prevents such a thing. Digital signatures take a digital certificate (algorithm based code) and permanently embed the signature into the certificate of the document. By embedding this certificate into the document, and signing to the certificate, you are creating a tamper evident document, one that if changed or altered would become invalid.
Anyway, we can talk more about that Friday.
In the meantime, you can visit my site, http://www.signix.com/, to read more about the difference.