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Denial Shock

It’s a patently bad idea to share my frustration regarding people who can make or break my career on the internet but after this weekend of working denials, I’ll take my chances.

The first denial I dealt with was the result of a ZPIC audit.  Somebody from AdvanceMed called a patient on the telephone and asked him if he drove. He assured her that he did.  The telephone interviewer, having heard what she wanted without assessing the patient, denied close to 30k in claims.

I actually visited the patient.  I also read his plan of care and medication list and couldn’t help but notice that he was on three or four pain meds that would make it very difficult, indeed, for him to get a driver’s license, but you never know.  The drive to his house included a 15 minute stretch on a country highway, another two miles down a gravel road and then the dirt road.   The trailer itself sat on over  an acre.  He had to climb five stairs to get inside and his scooter which was referenced in the denial was under the carport rusting.  It seems that it is fairly cumbersome to operate a scooter in a mobile home where three adults and three children live. 

But, what sold me on the homebound status, other than his five back surgeries, his lack of a vehicle or a license, his extensive medication list and the challenging physical environment in which he lived was the diagnosis of schizophrenia.  As early as that morning he reported having a conversation with his sister who died tragically two years ago.  He said he usually took Zyprexa and Seroquel but he didn’t that day because he had gone to the doctor to talk about back surgery.

The next denial was for $3,500.00.  It involved a claim with 7 skilled nurse visits, 9 therapy visits and a few home health aide visits.  The reviewer at Advance Med noted that there was no order for the visit to discharge the patient from therapy services.  I went back through the original scanned copy sent to the Zone and found the order.  So what?  Everyone makes mistakes and it was difficult to find.

The claim was not downcoded, you understand, but completely denied.  In full.  

My client appealed to Palmetto who upheld the original denial.  My job this weekend was to explain how the Home Health Prospective payment system worked to entities contracted with our government to monitor the integrity of Medicare payments.  That annoyed me.  I get paid by the hour so maybe I over reacted but I assure you that there are far more useful things I could be doing for clients. 

Lack of therapy orders for another client was the target of yet anther inane denial for a different client.  The client appealed AdvanceMed’s decision to Palmetto who reviewed the two signed orders (the 485 and the physician signed therapy eval and care plan) and agreed that AdvanceMed overlooked both orders.  However, the decision was noted to be ‘unfavorable’ (I love that word) because there was no distinction between short term and long term goals on the plan of care.

They were right.  What can I say?  Who really wants to hear that the entire course of therapy lasted only three weeks?

The most uncomfortable denial I worked this weekend was a claim that was part of a ZPIC request that my company prepared for a client.  They were paper charts pulled from old storage and our job was to put them order, verify signatures and notes, identify any outstanding vulnerabilities, scan 35,000 pages of documents and get them to the Zone on time.  I know you won’t believe this but we, uh, sort of…, well….. we made a mistake.

The claim I was reviewing had orders in it from 2010; a full year after the 2009 denied claim.  I missed it.  AdvanceMed missed it.  Palmetto missed it.  And now its back to me.  I found myself in the awkward position of pointing out that we sent in documentation that implied orders were written in March of one year that were actually written 12 months later.  Not only did Haydel Consulting totally miss the ball on this one but so did AdvanceMed and Palmetto, GBA.  I would like to take this moment to point out that unlike AdvanceMed, I do not have a 105M contract with my client. 

What can you learn from this? 

  1. At least once episode, fully explain the patient’s homebound status.  Being confined to the home due to pain and the need for help to leave the house will do on visit notes but once an episode, put it all together in context in case clinical record is requested for a payment review.
  2. If any claim is requested contains therapy, go buy a red Sharpie and draw a circle around the orders.  Make sure each page of the chart is numbered at the bottom.   Reference the therapy orders by page number in your cover letter.
  3. Include that the patient will win the Nobel Peace Prize prior to his or her death on all therapy care plans.  That way you can google the winners each year and monitor progress towards goals.
  4. The regulations state that all orders must be dated.  Apparently, it doesn’t matter what date you put on the orders as long as they are dated. 
  5. Haydel Consulting Services is not perfect or known for exploiting our warm and friendly relationships with Medicare contractors because we don’t have any.  Hire us anyway because we get results.  Somehow. 

Should I send an invoice to AdvanceMed and Palmetto or let my clients pass on my bill to them?  Maybe CMS could pick up the tab for educating their contractors.

I can’t wait to see what comes up next.  You’ll be the first to know if I am not in jail fighting accusations of healthcare fraud because I sent in orders that were a year late. 

Please keep me posted of any creative new denials you receive.

11 Comments Post a comment
  1. sahily #

    Well, it’s funny you post this because I just got a denial for a patient with a reason of non-homebound. This patient was admitted to a psych unit for an intent of suicide. Dr. Wrote on F2F form reason for homebound: patient is very weak, unable to leave home, high risk for falls, confusion.. etc (and i can’t remember what else). For them, that does not meet the criteria of being homebound……so now i am really confused.
    This patient was admitted for med teaching/management. Yes she has a caregiver (which they emphazised over and over) which ALSO needed to be taught!!!! Patient was taking multiple medications (which ALL OF THEM WERE NEW!!) which can cause cognitive impairment, orthostatic hypotension, intermittently, therefore making it difficult and a taxing effort to safely leave the home assisted OR unassisted and be independent outside of the home environment safely; Patient was at a high risk for falls due to factors such as current multiple medications, poor balance, lack of home modification, confusion, age and gait problems. After 2 days of being admitted, patient had a fall at home. She became dizzy and fell while getting up from bed and walking towards her couch to sit down. Patient was taken by her husband to the hospital due to increased pain on right wrist where she was diagnosed with a Right distal radius fracture.
    TO THEM, this was not enough…and honestly, I do not know how much they pay these nurses reviewers or whomever they are, but they surely need a better training.
    I am soo frustrated with this. Then you call Palmetto GBA and NOONE is responsible for this, there’s no number to call, except to make another appeal to yet another incompetent intermediary.
    Sorry, just needed to vent

    December 18, 2012
    • Curious #

      Don’t be sorry. It specifically states that the patient does NOT have to be bedbound to be considered homebound, but, I think maybe if “requires use of assistive devices (walker/wheelchair) or the physical assistance of one or more persons” to safely leave the home, that may have helped some. There are a lot of weak, confused, high risk for falls patients out there that don’t meet criteria for homebound. It sounds like maybe the documentation stopped just a tad short; what was the “etc.and can’t remember what else”?. She definately is skilled, so that’s not the issue. We continue to work on our documentation of homebound….”considerable and taxing effort” just isn’t enough. “The patient has moderate shortness of breath when walking from porch to car (approx 20 feet) and requires the use of a walker to do so.”

      December 18, 2012

    • Yeah…. I know the feeling. When people pay me to work denials for them, it is easy to see the exact cost on an invoice. If you do the work, it will cost just as much but it is much harder to measure.

      What’s sad is that while everyone is whining about the cost of healthcare, they have no idea how much of these ‘healthcare dollars’ are spent on things not even remotely related to health.

      December 18, 2012
  2. Curious #

    What is the criteria for exacerbating a diagnosis? Have been informed that “there must be an order related to the diagnosis which causes a change in the plan of care.” In other words, just a documented “abnormal” blood glucose is not an “exacerbation” unless the doctor gave an order as a result of the elevated blood glucose. If ZPIC denies for no documentation of exacerbation, how is that appealed if we don’t know what they want for criteria to exacerbate?

    December 18, 2012

    • Years ago, Palmetto defined an exacerbation. I cannot find the definition anywhere but I am certain I based my own guidelines on it. Read this post I wrote from a couple of weeks ago.

      December 18, 2012
      • Curious #

        Whoa. How did I miss that? Oh, well. Got it now. Thanks. That’s exactly what I was looking for.

        December 19, 2012

    • Don’t you think it is kind of funny that so many denials are based upon the lack of an exacerbation and they do not define it anywhere? I remember this from my very first job in Home Health which was like 20 years ago. I had it posted on the wall next to me while I wrote recertifications. I must have read it 1000 times which is why I remember it. Otherwise, it would be gone from my memory forever.

      December 19, 2012
  3. Curious #

    Just hilarious. What we can find are politically correct, vague definitions, mumbojumbo which leave much to interpretation (and imagination) and just plain old wishful thinking. Unless we are packing a 8x8x4cm wound, or administering IV antibiotics, or “doing” something very tangible, how is “skilled nursing” defined…politically correct, vague definitions and mumbojumbo. At least “they” do tell us when a B12 injection is skilled and when it is not and that administering eye drops are NEVER a skill. We’ll just have to learn the hard way and read your blogs.

    December 19, 2012
  4. Letty #

    Getting ready for my first ALJ hearing tomorrow morning. Patient was denied due to homebound status. We provided services for 3 cert periods, got the 1st and the 3rd claims payed for but the 2nd cert was denied due to no documentation on homebound status. It was documented approximately 7 times in the Oasis and in every SN note. What’s worse is that my patient was visited by Health Integrity contractors (an elderly couple) who only spoke English to a Spanish speaking patient 22 months BEFORE we admitted her to our agency. How am I supposed to know if she was homebound back then. Anyway this happened in 2011 and I am just now getting my day in court. I need a new career!

    March 11, 2013

    • I think it might be more accurate to say the people who denied your claim need a new career.

      March 12, 2013
      • Letty #

        Finally good news after a long and stressful battle. I was able to get the denial reversed. Judge asked if the patient had a driver’s license and I said I did not know but that patient was definitely not able to drive based on her medical and functional condition. He said, “Well if she wants Medicare then she has to give up her driver’s license. I politely disagreed with judge and told him that many patients are temporarily homebound due to certain conditions such as a TKR and are well able to drive once they have recuperated and of course at that time they no longer meet the homebound status and are discharged. He asked if we gave the pt. a notification of Medicare Non-coverage and I said no because the patient meet all the requirements to qualify for HH at the time of service and that notice was given upon discharge only. Just a few tips so that it might help someone else.

        March 12, 2013

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