Misdirection

Magicians often seduce their audiences using misdirection, enchanting and captivating them so they believe something that is not possible is happening in front of their eyes.  

Misdirection can also be used and often is used by Medicare contractors to slant the truth so that people believe something that is close to dishonest but technically correct.  Here’s an example.

You admitted a patient a few weeks prior, conferenced with the admitting physician and wrote a beautiful, complete and correct care plan. You read all of the hospital paperwork and double checked meds. On your second visit, the patient is bleeding like a stuck pig after stepping on a rusty yard tool.  Due to age, gait instability and well, blood, they are unable to assess and care for the wound. In fact, there’s no telling what would have happened if you didn’t happen by when you did.   You stop the bleeding, clean the wound and call the MD for further orders which you then carry out.  And yet, the claim for services is denied related to medical necessity. 

The explanation of the denial, 329 – Medical Necessity and Eligibility, reads as follows:

Ensure the documentation submitted for review supports all criteria for a qualifying skill.

For more information, refer to:

• Code ofFederal Regulations, 42 CFR- Sections 409.45 and 424.22
• CMS Internet-Only Manuals (IOMs), Pub 100-02, Medicare Benefit Policy Manual,

Chapter 7, Section 30.4

:

This says nothing specific about your patient or why the care given to prevent complete exsanguination wasn’t considered necessary.  

Since many of you like to read a lot of legal stuff, might I suggest you carry with you at all times, the Code of Federal Regulations, section 42 (42 CFR).Then go find subsection 424.22. It is listed above in the first line.  It is the section that delineates the contents of the plan of care and then describes what must happen to satisfy the Face to Face encounter requirement. 

Most nurses are familiar with Chapter 7 of the Medicare Benefit Policy Manual.  Note that section 30.4 is referenced.  Had the citations gone one step further and referenced section 30.5, the requirements for the Face-to-Face document would have been included.

Now imagine that the referring physician signed and dated the hospital discharge summary two days after they actually saw the patient.  When completing the date on the agency’s paperwork, they inadvertently placed that  date instead of the date that they actually assessed the patient.  

My first question is how on earth did that physician ever graduate medical school?  They have no right to a license and should be reported to their Medical Board. Still, The patient was clearly in the hospital and it wouldn’t take much for Medicare to verify that.  

But the real problem is that the patient needed immediate care that met the definition of skilled Nursing care with or without a correct Face-to-Face.  

And that is the misdirection.  Agencies providing reasonable care to an eligible patient are denied payment for their services because of an error, big or small, on a Face-to-Face document.  Had the agency been advised that the error lied in statutory documentation and not patient care, they could have addressed it.  Instead, a nurse likely wasted hours of time going through every note, the care plan and all of the meds to find the unreasonable and unnecessary care. I do not know of any agency that has time or resources to look for something that doesn’t exist.