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Getting Paid Part 2

Do the Right Thing

This isn’t some super moralizing appeal to your conscience to stop forging signatures or lying about visits you didn’t make.  Those kinds of people do not come here for news and information.  This is more of an appeal to nurses and clinicians to follow orders.

In the past several weeks, I have read many instances of nurses charting about why they did not do the right thing.

One of the most frequent excuses for a weight that is out of range and the nurse writes in parentheses that she used a different scale.  What does that tell you?  Here’s what it tells me:

  1. She does not know what the patient should weigh
  2. She has no idea if the patient is better or worse than before
  3. She did NOT follow orders
  4. She may be costing the agency money by setting her employer up for denials

I read a note last week that state the patient’s blood sugar was 370 but the son had only just now given insulin.   There was a note that the patient ate breakfast but no MD notification.  I suspect the patient eats breakfast regularly.  The question is whether or not the son is always able to give insulin timely.  If not, maybe a different kind of insulin would be better for the patient.

I have read may notes where the blood pressure exceeded either the MD parameters or just common safe practices and the nurse charts that the patient hasn’t had their medications yet.

In other words, nurses are spending time explaining away why they did not follow the care plan when they should be notifying the MD.  Maybe the blood pressure is extremely high every morning before medication. It certainly is more convenient if the patient strokes out in the morning but that is not a reason to let a patient’s pressure pound against their arterial walls every morning.

In order to get paid you must do the right thing.  If you do not communicate with the physician and if the care plan does not change, your patient is no longer eligible for services.  Explaining why YOU didn’t follow orders is not a billable skill.

Again, here is the language that I read repeatedly when appealing denials:

The records provided do not support that the skilled nursing services were reasonable and necessary for the treatment of an illness or injury. During the last certification period, there were no exacerbations, injuries or new diagnoses that would require continued skilled services.

Any questions?

Remember, answering to us is a lot more fun than answering to Palmetto or the Zone when you get ADRs.  And if you do get ADRs after reading this, I respectfully reserve the right to say, ‘I told you so’.

6 Comments Post a comment
  1. Dwelia Boyce #

    As a Clinical Supervisor, I sit here in the office reviewing Oasis and visit notes on occassion. I read all the things I know are not correct that I find during a chart audit and I provide educational material to support what I am saying like some of the information I read from you. However, nothing changes, the field staff continues to lie and do not act like professionals with degree like they are suppose to and for the life of me, I can’t understand why. The owner told me, my expections were to high but, I don’t know how to lower my standards for nursing because I look at patient as if they were my family. I have become very disillusioned because I see the same comments with the elevated blood pressure and they just leave, never following up and the sad part is it’s not caught until the end. I would love to be a surveyor, maybe this way I would feel I was in the least making management understand that having high standard for patient care is the way to be!

    September 11, 2012
    • Gail #

      Dwelia, If your field staff “continues to lie” as you stated, perhaps you should document some evidence of that and take to your owner. Our owner and/or administrator would NEVER allow nurses to “lie” in their documentation. Your other quality of care issues are a concern, I am sure; but if you know your staff falsifies any legal documentation, they aren’t the only ones who might eventually pay the price.

      September 24, 2012

      • I can think of no way more effective to lose a nursing license, an agency license or a provider number than by lying. I think one of the most underrated tasks facing agencies each day is selecting and evaluating potential employees, motivating current employees and retaining the good ones.

        September 30, 2012
      • Dwelia Boyce #

        I thank you so much for your reply, I only wish our owner was like yours. For many hm cares it seems the the bottom line is money, no one is concerned about the patient anymore, just dealing w/ f2F and getting good referral would help me tremendously. It is really sad and I agree it is the fastest way to lose a license and agency, but me knowing that changes nothing w/ my agency

        October 1, 2012

        • Nobody is more outspoken about the flaws in OASIS and the payment that I am. You may have noticed.

          BUT, it does work if you know what you are doing. It is much easier for nurses to understand than non clinical owners. Here’s what you do.

          Take your current census and I am willing to bet that your owner is still multiplying census by average payment to arrive at revenue. It works. But, I bet that at least 60 percent of your patients are later episodes and that your HHRG is under 2K. You probably will not know the margin but he will. If my psychic powers are accurate, he is making around five percent or less.

          Cut the number of patients in half. Cut the number of late episodes down to 30 percent. Now your average payment will be around 2200.00. But more importantly, the profits will be closer to ten percent. Do the math.

          200 patients X 1800.00 X .05 = 18k / 2 = 9k per month

          100 patients X 2200.00 X 0.1 = 2200.00 / 2 = 11k per month.

          I divided the end result by 2 because only half the patients are billed each month.

          So, you end up with less work, less patients, less back office filing, better care, less Medicare risk and wait for it……. more money. I can’t begin to figure out what is wrong with that scenario.

          October 1, 2012
  2. Dwelia Boyce #

    You are correct and thanks for your reply! only wish I had the authority to make changes w/in my organization

    October 1, 2012

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