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The Gimme’s

There is nothing in the world that I hate to see more than the ‘gimme’s’ – you know those denials that should have never happened.  It is especially painful to see them in documentation that otherwise met all Medicare criteria.  The good news is that these are preventable.

  1. MD failed to date his signature. 
    1. To reduce these denials you do have legal avenues to pursue.  For 485’s, keep a stack of attestations statements at the desk of the employee who receives and or files the orders.  When she notices that a date is missing, instruct her to copy the 485 and bring it to the DON or marketing department for rapid return to the MD.  If you do this as soon as it is received, the MD will remember signing it and will be less likely to refuse to sign.
    2. On all other forms, reverse the Signature and Date lines.  Make the date line stand out. 
    3. Pay a bounty for all undated signatures found in the clinical records.  If your home health aides came in one weekend and found 40 orders without signatures and you paid them $25.00 for each signature, it would still be less than one episode.  Who do you want your money to go to?  Loyal employees or back to CMS after you worked hard for it.
    4. Look into electronic signatures.
  2. Missing documentation
    1. In some patients, a single visit note can downgrade a chart to a LUPA.  Worse, you cannot demonstrate that you followed orders.  If an order is missing for a skill, then the visits for the skills are discounted, as well.
  3. No end in sight for daily visits.
    1. If you are below age 40, you may not be familiar with this reg but it is indeed a regulation.  Any time a patient is seen daily by the nurse for a period of 21 days or longer, there must be an end in sight to skilled care.  The only exception is diabetic patients.  Consider a patient that requires daily wound care and you provide it every day for 60 days don’t get paid for it.  You’re looking at a denial of 8k to 10k.  That’s a lot of consulting hours that you could have received from us.
  4. Face to Face Documentation
    1. Write a letter to all of your physicians explaining very clearly this condition of payment.  Furthermore, advise the MDs that you are aware of other agencies who do complete the Face to Face documentation for their signatures and in doing so, the docs may be unwittingly participating in Medicare fraud. 
    2. For physicians who have been late and uncooperative with face to face documentation, send someone to the MD’s office with a blank form at the time of the next referral and wait for it to be completed and signed before admitting the patient.  If it takes too long, start practicing the violin or, if you are an accomplished violinist, the tuba.
    3. If an MD has not returned the form and you have no other independent verification that the visit was made, prepare an HHABN for the patient and discharge them.  Explain to the patient that they absolutely can continue home health care services but they will be responsible for payment as their physician has not met the Medicare Conditions for Payment.
    4. If there is independent verification that the visit was made – written instructions, a copy of a prescription, etc., turn it over to the agency administrator.  On admit, look for these things!
    5. Do NOT become violent with the MD.  Legislation is being introduced in several states that will relax the penalties for Doctocide if lack of Face to Face documentation is used as a defense but thus far none of the new laws have been implemented. 
  5. Unlicensed Staff
    1. This happens very rarely but it is a nightmare when it does.   If you find out that a physician was not licensed in your state and your state did not allow physicians from other states to sign orders, every patient you have admitted to that doc is unbillable.  Worse, state Medical Practice acts vary.  Do not assume that because you did something in VA that it is okay to do in Montana.  Look it up.
    2. Similarly, Registered Nurses and Therapists who admit patients and have allowed their license to lapse have created documentation which determined an episode payment that is not billable. 
    3. This happens so rarely but when it does, it can cause total devastation to an agency.  Worse, it is usually not an oversight but a nurse or MD who has not disclosed that their license has been revoked.  This is easy to fix by having all of your clinical staff run and print their own licensure verification at the beginning of each quarter.  Hold their patients if they do not comply.  Get the office to verify MD’s every 3rd referral or once a month, etc.

Effective this year or maybe last, (who knows anymore with all the changes in health care), any provider who receives money from Medicare in error has sixty days to return it.  Failure to do so will elevate that erroneous claim to the status of a ‘false claim’ and the penalty is triple the amount of the original claim.

I hate the Gimme’s but if I worked for  Palmetto or one of the other MACs I would love them.  Once an undated signature is found, reviewing the rest of the chart becomes unnecessary.  On to the next.  But remember, I hate the denials resulting from a ‘Gimme’ but not as much as the agencies who end up on focused review because of the Gimmes or the owners who must have that conversation about trade school vs college with their kids.

4 Comments Post a comment
  1. Gail #

    Nothing wrong with trade school, but I get the point. The shame of it is that none of this would be necessary had Medicare verified and monitored all of the fraudulent reimbursements that created this whole mess in the first place. If I pay somebody $1200 to build a fence, I’m gonna be darn sure he builds it before I pay him. The other shame is that if there is a way to scam the system, somebody will do it; doctors, nurses, other heathcare professionals getting rich on the backs of others makes me nauseated. And who pays? The poor patient who gets denied by his Medicare-HMO because they don’t see a medical necessity and before we even have a chance to appeal, he’s in the hospital on life support. Excuse me, I’m gonna go throw up now.

    June 7, 2012

    • I wholeheartedly agree with you, Gail. What really irks me is how long providers who decide to scam the system are allowed to continue before they are stopped. Worse, agencies that do dumb things from ignorance are treated the same as criminals.

      Like you, when I spend my money, I like to see what I paid for. I know it’s impossible for Medicare to look at every claim but if every provider knew they would be receiving random ADRs frequently, they would make sure to clean up their act. It would further provide CMS and contractors with information on where education is needed. For about ten years none of my clients had any ADRa.

      The percentage of healthcare professionals who scam the system deliberately is minute but that isn’t what you would think when reading CMS press releases. The number of agencies who have loosely interpreted regs without any repercussions whatsoever is huge. For those that acted in good faith, there is no longer an option to voluntarily enter into a corporate integrity agreement. I think CMS would save a lot of money if agencies could self report and clean up their act with oversight from the contractors. Most agencies would rather do that than go to jail or lose their livelihood. The investigations I have read about recently were ongoing for years. The infamous Jacques Roy put his money offshore. CMS is only going to incur more expenses prosecuting him. It should not take five years to investigate someone as blatantly fraudulent as Javques Roy.

      Finally, there is an agency here that was owned by a married couple. They were clearly fraudulent. Only the husband went to jail and the wife was allowed to continue operating the agency. That never happens to agencies who do dumb things in good faith. Only criminals get to keep their provider numbers after a long history of defrauding the government and in this case, their employees as well.

      Excuse me. I am going to throw up now.

      June 7, 2012
  2. jan Treptow #

    Of course, as always, this is very pertinent & sadly true information. I will be sure to pass it on to my new nurses, so that they understand the “whole picture.” Thanks, jan

    June 7, 2012
  3. Gail #

    I had to come back to read your last paragraph one more time; just to be sure my eyes weren’t deceiving me. The wife continued operating a fraudulent agency????? I am reading that right? And they’re still in business? How was that justified? Did you see where a guy was arrested for giving a homeless man $2? He dropped one of the bills and was arrested for littering. Really. Has common sense been completely abandoned? I’m confused.

    June 7, 2012

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