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Urgent Call to Action

The short title is the Medicare Fraud Reduction Act. This ‘act’ places caps on your aggregate number of episodes.  Representative Jim Matheson, a democrat from Utah introduced a bill into congress on October 4th, and Representative Brett Guthrie, a republican from Kentucky co-sponsored the bill.

H.R. 3245 of the 113th congress (you have to state the 113th congress or web results will show cocaine sentencing laws) as I understand it, states:

  1. No episode will be paid for after the agency meets its caps.
  2. The cap is 3.3 episodes for agencies that reside in a rural area
  3. The cap is 2.7 episodes for all the rest of you.
  4. When more than one agency sees a patient, the episode credit is divided proportionately between the agencies on a percentage of episodes basis.

If this looks familiar to you, it reads exactly like the proposal The Partnership for Quality Home Health (click to see members) submitted to Congress signed by Eric Berger.  Note the 4th paragraph of page four of the proposal.

And yet, both Eric Berger, CEO and paid lobbyist for The Partnership of Quality Home Healthcare, and Bill Dombi of NAHC deny having anything to do with this Bill.  Eric Berger pointed out that the language was available on the internet for anyone to use and apparently somebody did.

My first response was that one of them was being less than truthful but their denials were direct and to the point.  I do not believe that either man would commit to writing a falsehood.

You are obviously free to your own opinions about caps but I do not like this idea not one bit.  However, the best I can do is make sure you know about it so you can act on it in the manner in which you see fit.

In researching the so called recommended targets for fraud reduction, I found some interesting facts which I am certain have no bearing on the length of stay required by a patient.

  • In Bogalusa, Louisiana, 15 percent of residents have diabetes.  This is twice the rate of the rest of the country.
  • In East Carol Parish, a full 57 percent of children live in poverty which I assume is a fairly decent indicator of the overall economic status of the community.
  • Hancock county in Tennessee doesn’t report on drug use or alcohol use but they have more than triple the number of deaths from motor vehicle accidents.
  • Like the other hot spots, Hancock County has high unemployment (50% higher than the rest of the state) and very poor educational levels.
  • There are three counties in Mississippi that hit the target list.  Consider that in Mississippi taken as a whole, 32% of children grow up in poverty.  For the three fraudulent counties, the percentages are 46%, 52% and 53%.  If they are fraudulent, they aren’t very good at it.  Someone should be getting the money stolen from Medicare.
  • In one Mississippi county, a full 78 percent of people had water exceeding a violation in the past year.
  • Perhaps the most tragic is the violent crime in these three counties.  In Mississippi, 280 people out of every 100,000 is expected to become a victim of violent crime.  The county with poisonous water (Sharkey) has a very low rate of 72 incidents.  Jefferson County counted 443 victims per 100,000 but Claiborne county takes the prize with 770.
  • In Madison Parish, Louisiana, you have a one in ten chance of being a victim of violent crime which is a shame because it is one of my favorite places.  I had no idea I was in such danger.

Add it all together and you have a bill introduced to congress that will limit access to care to elderly people without resources.  Their families are stressed and stretched thin.  Neither the patients or their families have enough education or money to log on to a computer much less email their senator.  They are the men and women who didn’t need an education to farm our land and feed us for fifty years before they retired.

They are disproportionately African American and disproportionately elderly in the counties where they reside as the younger people who could leave have left.  For the most part they have outlived their usefulness and have no voice.   If we don’t speak up for them, who will?

Of course, I have gone way off track.  None of these tragic figures in any way contribute to longer lengths of stay.  Rather, the home health agencies commit fraud.

Most of my data was obtained from the County Road Maps.  It is a great site where you can find a plethora of information about your community and there is even grant money available if you can come up with a plan to address your data.

Its important that all of our voices are heard.  Even if you disagree with me, contact your state representative.  I am going to contact mine and I will also email and call Bill Matheson and Brett Guthrie every day for no other reason than I didn’t have any time off this weekend because of their ill advised nonsense.   If you click their names, you will be taken to their contact forms.

If for some reason you are inclined to like the proposed reform, I would like to hear from you so I could begin to understand who would think this was a good idea.

Comments welcome.

15 Comments Post a comment
  1. Mary Ann Knee #

    This is my message to the two morons who think this is a good bill:
    This bill is an abomination and a death sentence to our diabetic seniors as well as our chronically ill patients requiring skilled care on an ongoing basis.
    If your parents needed care would you like us to deny them? We could tell them then that you just think they should die. Please reconsider this terrible attack on the elderly and the infirm.

    October 14, 2013

    • Chances are the two representatives limit their representation to the rich and healthy. After all, what good is an elderly diabetic with no legs? It’s not like they contribute to political campaigns and they can hardly go door to door soliciting votes.

      This current war on fraud is nothing more than abuse – by out lawmakers directed to healthcare providers. Now go write your letters and share the post with everyone you know!

      October 14, 2013
  2. Daniel #

    I haven’t read the recommendations put out by Partnership for Quality Home Healthcare, so I cannot make definitive statements about them. But listened to and read other statements from the Bureaucrats and “representatives” in Washington. They never seem to factor in the overall savings of HH vs hospitalization. Those chronically ill patients are the very people whom we get out of the cycle of multiple hospitalizations and ER trips. A reasonable cost benefit analysis shows our value. So now, these two legislators (and apparently some people even from within our ranks) want to cut off our collective noses to spite our face. Nonsensical.

    October 14, 2013

    • There is a link to the Partnership of Quality Home Healthcare’s recommendation in the article. I have never subscribed to the design of care based upon arbitrary numbers. However, they deny putting this out there. So, who knows? Maybe these representatives just woke up one morning and arrived at the same idea independent of anything that The Partnership did. I will admit that I am livid at the person or organization who did this and would like to know who is responsible but honestly, my feelings are not important.

      What is more important than even me is that we get the word out to as many nurses as possible as soon as possible so this bill dies before it gets legs.

      I do a lot of work with lawyers. We have an agreement. I don’t practice law and they don’t practice nursing. Every time the agreement is violated, very bad things happen.

      If saving money were really the goal, then may I suggest that we keep trying to cut costs off a system that does not consistently work and try some new approaches? I agree that it shouldn’t cost 10k to administer insulin to a diabetic twice a day. On the other hand, our choices are to find a willing and able caregiver and if we cannot, continue to give the meds and charge Medicare. Paying us a reasonable amount extending the cert period for diabetics would go a long way to reducing costs. Or, have you looked at the Revised Beers Criteria (2012)? We could save literally billions of dollars if we gently introduced this to physicians and asked for medication adjustments that adhered to the recommendations. That doesn’t include the treatment of side effects and non-compliance. We could save a few lives and dramatically impact hospitalizations in general if we were paid decently and protected legally in giving flu vaccine to anyone and everyone. While it is within the scope of the regulations, many states, including Louisiana, run into problems with the pharmacy board because nurses may not ‘dispense’ medications or carry emergency drugs. The list goes on forever but instead of actively pursuing any of these options, we are fighting denials and trying to offset legislation that was sort of snuck into the mix of things.

      October 14, 2013
  3. Pamela Willey #

    I really don’t know how these people come up with these stupid ideas, apparently they have never dealt with a diabetic with gangrene that had to have both legs amputated. But then again I don’t understand how ordering DME 200 miles from my patients home is saving Medicare money. How someone who is released from the hospital as ALWAYS on a Friday and is on 4L continuous O2 will receive their O2 before their portable runs out. As an owner I am stressing ALL weekend. MY preferred DME can pass through Orange county on the way to Deweyville but can NOT service Orange. I have filed complaints with Palmetto and asked how getting DME is going to save Medicare money ordered from 200 miles away and if the O2 is not delivered in a critical timeframe the patient will be gasping for air on the way back into the hospital thus costing thousands of WASTED Medicare money. His response was “I do work for the government and they have been good to me and my family”. Lets see how he feels when it is his family member! Yes, I know I got off the subject, but I am fed up with stupid people running our country!

    October 14, 2013
  4. MAK #


    October 14, 2013

    • When something goes wrong with my computer network or I get arrested (again) or my air conditioner breaks, I try to determine who the best person is to go to for advice. I do not go to a lawyer to fix my air conditioner and I would not let the AC dude represent me in court. But for some reason, these two representatives have seen fit to determine the best care for patients. They are both lawyers, I believe and they have no idea what they have proposed.

      Please take the time to contact both representatives and the yoyo’s who introduced this bill. I did and I will continue to do so until I know that we are heard. Go ahead and contact representatives from other states, too, if you have the time.

      Make sure all of your coworkers take action as well.

      Years ago, my friend worked at Dow Corning Wright. She told me that they were investigating the safety of silicone breast implants and she had to testify in front of the senate. At that time I had a patient whose chest would not close and so a plastics guy closed it with a mediastinal flap. I told him what was going on with my friend and Dow Corning Wright and he blew me off. He said there is no evidence whatsoever that silicone breast implants cause disease. He was right but the facts did not matter. A senator’s who wife became ill after having implants that started the ball rolling. I think the senator whose name escapes me honestly believed the implants caused his wife’s autoimmune illness but he was a lawyer – not a medical researcher. Since then, it has been demonstrated repeatedly that the silicone implants are far safer than the saline and are in use again. It did not prevent Dow Corning Wright’s implant division from going under. Just saying. Bad things happen when lawyers start practicing health care.

      October 14, 2013
    • Pamela Willey #

      MAK, their thinking is beyond my thought process, to me it’s common sense, do the math! It’s a hell of a lot cheaper for home health to care for patients in the comfort of their home versus the hospital AND it is a proven fact people heal faster in the comfort of their home. I just don’t understand that these people in congress with these high educational degrees do not have ANY common sense. But if they did the math you would think it would prove the fact!

      October 15, 2013

      • It’s not beyond my thought process. I do not for a minute believe this is about healthcare fraud and abuse.

        Medicare does not cover funerals or adult literacy. The won’t pay for gas money to get a patient to the doctor. Medicare does not make up lost earnings when a grown child must take time off of work to take Mom to her MD appointment. If you made minimum wage and had to choose between feeding your kids or taking the day off to carry your mamma to the doc, how do you choose?

        Some of these patients will end up in the hospital. Many will not.

        If you saw the financials of these agencies, you wouldn’t even consider that they were fraudulent. Nobody greedy enough to commit fraud would operate in these areas.

        And no company who is more concerned about margins than patients would consider operating in these areas.

        In urban areas, the problems are different but real all the same. How many agencies do you know that will go into the projects in Chicago’s South Side. I have one client who will. You should read those charts. One of our Coders works two days a week at a free clinic in TX. Besides a huge language barrier, she says they see A1C’s up to 15 on a regular basis.

        But it’s fraud you understand that is driving utilization.

        I am not dumb. I know there are fraudulent providers in these areas and others. Here’s a novel idea – arrest them. Leave MY clients and all the other agencies just like them alone.

        I’ve worked a lot of ZPICs over the past few years. I know what fraud looks like. Why can’t the people paid to investigate spot it as easily as me?

        October 15, 2013
  5. Delaine Henry #

    Jimmo v Sebelius anyone? Medicare just settled a class action suit that clarified patients with chronic illnesses have coverage for skilled care to prevent or delay further decline. Caps would deny Medicare patients coverage that took them a lawsuit to obtain.

    October 15, 2013

    • Delaine, I fully expect patient dumping to manage lengths of stays will ensue. If this bill gains any legs, I am going to invest in a computer program that will do the math for agencies. Here’s a problem. What if you have a patient on service for two episodes early in the year and another agency picks up the patient later? Without violating HIPAA, the initial agency won’t know and therefore it would be difficult to plan unless you assumed you were the only agency seeing the patient in the year. Not being a biller, is it even possible to go and research former patients in the CWF?

      October 15, 2013
      • Delaine #

        Yes when an agency gets a referral now they check the CFW to verify eligibility. As of now we look for overlapping care with other agencies, open liability claims, open hospice election periods, etc. If this bill somehow becomes law, agencies will have to use the CFW to confirm if a patient has had prior home health and for how long.

        October 15, 2013
  6. Delaine Henry #

    To be clear, in the lawsuit settlement Medicare says patients have always had this coverage and that they are just clarifying what has always been in place and adding clear language to the Medicare coverage manual.

    October 15, 2013
  7. mak #

    I think congressmen need a fifth grade calculator to track cost of a patient from 911 to hospitals to rehab @ home . Hospitals and nursinghomes stays are so embarassing for an average patient they hardly discuss them . Most of my patient remember that they waited all day in their bed for their doctor and when he came it was for few minutes or they were sleeping. Here I donot blame doctors all they got paid was 150 $ at the most and hospital made 25 thousa d dollars for that day. IT IS A UNBELIEVEABLE, HISPITAL ARE IN BED WITH NURSING HOMES OWNERS AND KEEPS PATIENTS WITH THE HELP FROM THESE HOSPITALITiST IE their own employed doctors another day to qualify them to a SKILLED NURSING STSY.COSTING THE MEDICARE ANOTHER FIFTY TO HUNDRED THOUSAND $ s.Rather to send patient home with HOME HEALTH SERVICES.. The only way to CUT COST IS HOME HEALTH AND HHA SHOUKD NOT BE ALLOWED TO BE OWNED by NONLICENSED HEALTHCARE INDIVISUALS. TO PREVENT FRAUD. BUT PEASE DONOT RUSH GRANDMAS AND GRANDPAS TO HISPITALS UNNECCESSARILY. .I have seen grand dotors calling 911 from california and admitting parents unneccessarily to hospitals costing medicare hundred of thousands of dollars.They shuld call nursing @a designate home health agency to visit and decide if patients for nonemergency care should go to hospital.Once hospitalized COST OF CARE GO OUT OF CONTROLE..Hospital aquired infections and disease are growing…………with growth in Medicate COST. Seniors please FOR NON EMERGENCY CALL HOME HEALTH NURSE.ALL YOU WANT.AND THINK BEFORE YOU DIAL 911.

    October 19, 2013

    • Mak, one thing I don’t write alot about is my work with other post acute care providers. One of my clients started as an accountant at a hospital and then bought a home healthcare agency. He then picked up a nursing home here and there and a couple of hospitals came available and he purchased them. After the second nursing home, I did all of his regulatory work. Changes of Ownership are always complicated but when real estate is involved, it gets worse. About 7 years ago, he sold it all for 106M. I did the regulatory work for that deal, too. I say this with complete sincerity. In addition to being a very good businessman, he is the most ethical person I know when it comes to patient care. This is not to say that he is sentimental or supremely virtuous. He is not. He’s good at making money because he knows that in order to do well, his companies must perform. In order for a healthcare company to perform, he needs to have strong clinicians working with him.

      I have also worked with complete psychopaths who dually own two or more post acute care facilities such as rehab hospitals, LTACs, home health agencies, hospices, etc. I approached a former client about not paying his staff and his response was that his dog needed to go to the vet and his kid needed braces. I swear to you that happened. Another client complained for about an hour about his cork floors and how easily they are damaged and after spending all that money on cork, he was going to have to replace them with oak. He owed me 15k at the time. The amazing thing is that these people care a whole lot of what others think of them.

      I do not believe you have to be a licensed healthcare practitioner to own a provider. I nursing, we have a nasty habit of promoting our ‘good clinicians’ to management positions. There is nothing inherent about nursing that makes one good at management and yet, how many agencies have you seen invest in teaching management skills to nurses?

      What I find works best is when the accountants, operations and IT folks respect the clinicians and the respect is reciprocated. I don’t give a flying flip about aging reports, AP, etc. as long as bills are paid and the clients receive good care.

      You are correct about rushing people to the hospital. That story goes both ways. For a long, long time, home health agencies sent patients to the hospital to avoid making weekend visits. We have been made aware that we can lose our license, go to jail, grow warts on our thighs and burn in hell if our clinical judgment is off and a patient does poorly so shifting the responsibility to the hospital is an easy decision. They are bigger, tougher, have more staff and a crash cart around every corner. If you mess up an order at taco bell, the customer gets a free meal and if you do it enough, you get fired. If you mess up where a patient life is concerned, you can’t give them a replacement life.

      The problems start when non-clinical owners start making clinical decisions. A nurse called me last week because some guy related to the owner of an agency told her to admit patients. Other nurses have complained because they were forbidden to discharge patients. I sat in a meeting where a highly paid consultant who is not a nurse reviewed some global numbers and told the agency their length of stay was too short. I had actually worked with the nurses and knew their average was artificial because they had a boat load of patients from a cardiovascular surgery group who ordered three visits and three visits only. Just like congress shouldn’t put a cap on episodes, this consultant should not determine length of stay based upon reports.

      But yes. In rural areas where I work, patients are slow to go to the doc and will often use the ER as a doctor’s office which is ineffective in so many ways I cannot count. We can reduce ER visits and hospitalizations and lower total costs of healthcare. I wholeheartedly concur. I wouldn’t stop there, either. We also need to close the cookbook sometimes and go out when the patient needs us as opposed to an arbitrary schedule designed by a computer. Just saying…

      October 21, 2013

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