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Work with Me, Folks!!!


deniedFor the past several months, I have been arguing with pretty much every payor source for home health there is trying to get clients paid.  After working with dozens of clients in multiple states, I am fairly confident in stating that some of you simply do not want to be paid.  If you did, you would give me and other consultants and lawyers something with which to work.  Just to be clear, I cannot work with:

  1. ‘Take meds exactly as ordered’.  (variant:  take meds at the same time each day.)   It does not require the skills of a licensed nurse to tell the patient to take meds exactly as ordered. The general rule of thumb is that if you can learn it on Oprah, it probably isn’t skilled.
  2. Duplicate medications.  Alone, duplicate medications place a patient at high risk for adverse events.  Combined with number 1, it shows anyone who cares to read that the patient should not take meds exactly as ordered.
  3. I read this in a clinical record:  I noticed the patient had enough money to buy cigarettes, but claims she can’t afford her medical supplies.  Work with me people!  You don’t get paid for your personal judgment.  The patient was at 77 percent of the poverty level. Refer to evidence based practice when you feel tempted to commit to legal documentation your personal disapproval.
  4. Prior to charting edema on a lower extremity, please ensure that the extremity is present.  I promise that if you have check boxes for right and left pedal edema and you pull all your patients who have less than two lower extremities, you will find phantom edema.  The same applies to diabetic foot teaching, pedal pulses, etc.
  5. It is not enough for a physician to document that a patient has a diagnosis.  You must also know what the diagnosis is and how to provide nursing care for the condition.  I just read an admit for a patient who was referred with Pickwickian Syndrome which was named for a very round faced portly character in the first novel written by Charles Dickens.  Because Mr. Pickwick was known largely for his girth, the condition has been renamed  ‘Obesity Hypoventilation Syndrome.  There were no orders for diets or attention to respiratory status.  I  don’t think the nurse looked up Pickwickian, do you?
  6. Diabetes Type I and II are not interchangeable.  Work with me, folks.  These older names for diabetes confused a lot of people so they have changed to simply Type I and Type II.  Type I diabetes accounts for less than 5 percent of diabetes in the elderly.  What on earth are y’all gonna do when when they recognize diabetes 1.5 as a separate diagnosis? (For now, just code as 250.00.)
  7. MD Awareness Month.  It must be MD Awareness Month because every day I read about an MD who is aware.  It goes something like this.  ‘Pt’s blood pressure is 190/100.  Patient has not taken medications.  MD aware.’  I believe that is a convoluted way of stating that you didn’t call the physician as warranted by the MD stated parameters.
  8. Someone named Pt/Cg is wandering through the homes of all home health care patients in the country.  Typically this occurs in computerized documentation that has not been edited correctly.  It makes less than no sense that you taught pt/cg in an Assisted Living Facility that Alzheimer’s is a progressive neurological disease which results in mental deterioration and eventually death.  Which caregiver did  you teach?
  9. Notifying the caregiver is a bad idea.  Imagine if you had an INR come back high and you notified the caregiver to hold the Coumadin and documented that you did so.  What if the patient had multiple caregivers and none of them held the coumadin?  What if the patient had a bleed into their brain and none of the caregivers remember the conversation and you didn’t write down a name.  Think that’s over the top?  It is.  But it happened to a client a year or so ago.  Caregivers have names for a reason.  Use them.
  10. Repetitive teaching.  The second most common reason for denial is that the documentation does not meet the standards for reasonable and necessary care.  Teaching is the most frequently provided skill in home health.  You with me?   So, in order to be paid for your services, you must teach original material or have a reason for re-teaching.  It is unreasonable to teach diabetic diet, foot care, skin care and insulin injections in a single visit.  Don’t chart that you did.  Use teaching guides.  Your patient is elderly, in pain, has poor vision, intermittent confusion, and takes drugs that impair mentation.  That might be something to keep in mind. Take your time.  Teach at the pace the patient learns and document what you did.

So, maybe I am a little frustrated this weekend but I love my job and I love home health and I take it a little personally when payor sources deny claim after claim sending the message to my clients and colleagues that what we do is not worth getting paid.

17 Comments Post a comment
  1. MD aware ?? i remsemble that remark..

    ________________________________

    Like

    February 18, 2013
    • Riddle me this, Dr. Burnside….. Do you wake up every morning and meditate and suddenly see the glucometer readings of all your patients?

      Just because you are a physician and this was written for nurses doesn’t mean that you can’t learn something here. Even you can take the time to review the patient’s medications. I’m not talking about the form in the back of the chart. I’m talking about the pill bottles from ten different pharmacies written by five different docs.

      Do you have any diabetic type 1.5 patients? (latent onset, adult type 1 with avg of 5 years until insulin dependency?) What about type I patients who progress to types I and II?

      I do fear that your comments regarding the personal lifestyle choices of the patient are likely unrestrained. Sure, you would rather suture their mouth shut now instead of cutting their legs off later but it is not your decision. If everyone ate well and exercised, you would not have a job. Agencies would have no referral sources. I would have no clients and yes, Hale, it is all about me.

      Like

      February 18, 2013
      • lccoww #

        You go girl!!!! I am with you on all of this.

        Like

        February 18, 2013
      • Stacey Ufer #

        You are a troll. This is not productive.

        Like

        February 19, 2013
        • Then might I suggest you write your own blog that is productive. It is always easy to find fault with what others have done. There is no law that states you must read my blog. You are free to navigate back to Facebook if you do not find my information useful.

          If your ‘troll’ remark is in reference to my height, keep in mind that short people are less likely to break their hip when they fall. Physics, baby. The laws of physics were promulgated with me in mind.

          I hope you are tall.

          Like

          February 19, 2013
      • Gail #

        Why does some of this blog has one word at a time showing up on the right side of the screen? Looks weird from here.

        Like

        February 20, 2013
        • Gail #

          I fixed it myself. I changed from Internet Explorer to Google Chrome and Ta-Da, all fixed.

          Like

          February 22, 2013
        • I don’t know. I love the theme but I just noticed that a lot of things are missing. When I get this project out the door, I may have to make some changes to the theme in general. It doesn’t have a link to our ‘about us’ page with contact information. It sort of defeats the purpose of having a blog, don’t you think? Or at least one purpose.

          Like

          February 26, 2013
    • Laurie #

      I am printing your comments off as I type. The staff need constant reminders on the craziness of some of their documentation. We have been constantly talking about this topic especially considering the increase in the number of ADR’s we are seeing. I have thought about bringing the group together for another education session, but I like the facts communicated to them by another “real” source other than us. At times I believe it resonates more, hits home, and makes them think that weren’t not all crazy here because we keep talking the same issue over and over again. They are tired of it, but so is management, quality dept etc……

      Like

      February 19, 2013
      • I have worked with many very embarrassed DONs and QA nurses who are astonished when i teach their clinical staff who are in turn in awe of my insight and sound advice. In truth the staff has heard what I have said many times over but the validation from someone who has no horse in their race goes a long way.

        Don’t ask me why this phenomonem occurs but it appears to be universal. I would try to correct it but that would reduce my income significantly:)

        Like

        February 19, 2013
        • Laurie #

          I meant to say that I was printing off your blog, not the comments, as I thought you made some excellent points. I have shared with them a couple of your blogs and they were astonished at how close to home it all hits. When “you” are not a horse in their race then you have an automatic advantage in getting them to take a second hard look at the facts being presented and develop a buy in……. or at least have the tendancy to listen more attentively. When can you come here and have a session with our nurses???? Wishful thinking I’m sure of it!

          Like

          February 19, 2013
  2. Stacey Ufer #

    a troll (pron.: /ˈtroʊl/, /ˈtrɒl/) is someone who posts inflammatory,[1] extraneous, or off-topic messages in an online community, such as a forum, chat room, or blog, with the primary intent of provoking readers into an emotional response

    Like

    February 19, 2013
    • Stacey Ufer #

      I mistook your response to the MD as a response to YOUR blog. I thought the info in Work With Me, Folks was great. I owe you an apology for calling you out on trolling, but then you did wish a hip fracture on me!

      Like

      February 19, 2013
      • Hale is an old and dear friend of mine. Like most docs, Hale seldom writes enough which is a shame. He is one of those rare physicians that can put it all together really quick. He is great with ICU stuff where there isn’t a lot of time to mull things over and his diagnostic skills are greatly needed. As far as office communication skills, hmmmm, I’ve never seen him in action. He knows his stuff but how shall I say this delicately….. The man is opinionated and has no reservation about sharing his opinions. I can’t stand people like that, can you? Reminds me of an irreverent home health blogger…

        Glad you liked the blog. I had serious concerns about you at first. There is a tendency to make things more complicated than they have to be. By reducing an issue to it’s bare bones and shining a light on it, you can’t help but see it if you look. The real key is in getting people to look. I love my job and very few things are so sacred to me that I can’t poke fun at them. For some people, that makes it easier to see themselves in the content. Other people do not share my warped sense of humour. That’s okay, too. One thing I can guarantee is that nobody ever calls me after reading my blog and expects a silent, studious type to show up at their agency to help them with a problem. And I think by now that agencies who are not willing to be compliant so they can make more money at the expense of the good agencies pretty much know not to call me.

        When I said I hoped that you were tall, it was simply because tall people can reach the top shelf of the cabinet and carry an extra five pounds better than short people. Well, at least that’s what I mean now.

        j

        j

        Like

        February 19, 2013
  3. Gail #

    J, You wrote: “Very few things are so sacred to me that I can’t poke fun at them. For some people, that makes it easier to see themselves in the content. Other people do not share my warped sense of humour.” But, it sounds like something I would say. I can’t tell you how many times I’ve gotten “in trouble” for my warped sense of humor. Since life is the most sacred thing I can think of, let me say this about that: Life is too serious to take too seriously. It’s like the guy with one leg who dressed up as the “Christmas Story” lamp for Halloween; make the best of what you got. So, I’m warped. You’ll just have to get over it if that makes you unhappy. Read “The Freak Factor” by David Rendall. You’ll see.

    Like

    February 22, 2013
    • I will read the Freak Factor. Life is funny. Period. I know everyone thinks I have this glamorous job and that I am surrounded by interesting people all day, every day but the truth is, and I know this is hard to believe, sometimes it becomes a little tedious reading clinical records:) A CMS 855a is probably the least exciting project on the face of the earth. Oh, and a civil rights package is more fun than you can imagine! But my clients are great, my coworkers are wonderful and if we didn’t find something to laugh at, well…… we would die of boredom. Is there a code for that?

      Like

      February 26, 2013
  4. Gail #

    I’m not sure people actually read Reader’s Digests anymore, but my Nana and Papa used to read “Laughter is the best medicine” from it when I was a girl. So, I grew up reading it too. Here’s an excerpt from some of the best.

    Lying on his deathbed, a loving husband was wavering between life and death when he thought he smelled chocolate chip cookies baking. They were his very favourite, so he dragged himself out of bed, crawled to the kitchen and was just reaching up to take a cookie off the plate when his wife slapped his hand with a spatula.

    “Don’t touch!” she commanded. “They’re for the funeral.”

    When I was a Hospice nurse, I told a patient who asked what my husband did for a living, that he worked for a local funeral home, but that we weren’t in cahoots or anything. He studied me for a few seconds and nearly died laughing.

    Like

    February 28, 2013

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