Skip to content

Palmetto’s Claim Review Tool

If you want a variety show, try asking various home health providers to describe their QA program.  The answers you might get will range from reviewing all notes before they are locked or filed to reviewing records for hundreds of indicators.  If you ask what is done with this information, they say that it is used to identify notes that need to be ‘fixed’ if they can be.

This is a tiresome process and doesn’t accomplish anything lasting.  It does not improve your operations and it doesn’t assure quality.  It keeps your staff busy, though.  It causes embarrassment on survey when the process is set aside because the quality assurance nurse is needed in the field.  It can result in widespread failure to meet billing compliance standards.  But it doesn’t make things better.

Palmetto GBA has come up with a tool for you to use.  It is likely the same one that is used by their reviewers when looking at ADRs.  It goes through 78 items to check for when clearing a chart for billing.  Many of these are related to individual therapies and would not have to be repeated if a patient only had one therapy and would not need to be addressed at all if no therapy was ordered.  But their tool is for a single chart.  I have taken that tool and put it into a document for ten charts.  Then, because I really didn’t like it much, I made a few changes. The QA Spreadsheet is yours for the clicking.  Note, the first three pages make up Palmetto’s version and the last two are Haydel Consulting Services’ version.

Remember, that in addition to data that you collect, you have OASIS outcomes and Satisfaction data available online.  Do not get carried away in your data collection.  Get carried away in your projects.  Consultants love a project.  Data in and of itself is not useful.

Get Busy

There are not many differences between the Haydel Consulting QA tool and the one from Palmetto.  In ours, all orders and frequencies are grouped together.  In theirs they are broken out per discipline.  I added homebound to the top of the list so that when you get to the therapies, you can quit after you have completed review of the therapies seeing your patient.

After deleting multiple indicators for each discipline, several were added based upon our experience.

  • Is teaching original and relevant
  • Diagnosis Coding appears accurate
  • PT/INRs according to orders

The last is not a billing requirement but we have seen patient harm come from failure to monitor anticoagulant therapy so it is worth the extra effort.

Other than that, this is a billing tool.  With the exception of the PT/INRs, there isn’t too much here that reflects the quality of the care that is delivered.  So, go to the bottom of the page and add a couple of indicators that you believe need attention.  Consider supervisory visits, general lab, missed visits, wound care or medication compliance.  All of these indicators deserve attention.  Because this tool is used on every chart that is billed to Medicare, you can quickly get an idea of what might be a problem for you.

And that folks, is only step one so keep it simple.  Set priorities and work on the most pressing needs.   Address the critical problems.  You may find that some of the less critical problems disappear by themselves when the larger problems are resolved.

There are any number of ways to correct an operational or agency wide risk  and the most effective ways hit a problem from all sides.  Keep in mind that it takes about 90 days to really change behavior.  It is not enough to have an inservice or tell your staff how to do something or not do something just once and expect it to stick.  Send reminders.  Hold out examples of documentation that shows a nurse really ‘gets’ what you taught in the inservice.  Provide feedback often.  Be patient.   Be creative. Keep measuring until the indicator is where you want it to be.

Then, when you get an ADR or if a surveyor visits, you can relax.  You will be paid and you will have something to show and tell when the surveyor asks about the QA program.

Now would be a great time to implement this for December’s billing.  When 2016 rolls around, you can have a real QA project based upon your findings.  When 2017 rolls around, the same amount of work you do today will seem like half as much.

One Comment Post a comment
  1. Marguerite Coan #

    Marguerite Coan

    December 1, 2015

Leave a Reply

%d bloggers like this: