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Posts from the ‘ADRs’ Category

Jun 11

3 Comments

NAHC v US DHS

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

I have never been a big fan of associations and organizations.  I am not a joiner in general.  Specifically, I have been very frank about my feelings towards the National Association of Home Care and Hospice.  I believe that in the past they took on causes that benefited some agencies at the expense of others.  In many ways, it is almost impossible to be an organization representative of all agencies of all sizes in all parts of the country.

As of June 5, that changed.  William A. Dombi, attorney for the plaintiff – your association – has filed suit against the US Department of Health and Human Services.  NACH is challenging the requirements regarding documentation of the Face-to-Face encounter.  They allege that Medicare is enforcing the Face to Face encounter requirements in ways that were never intended and are not legal.  They note that these retroactive denials are made outside of the consideration of the care needed by the patient or the quality of the care rendered to the patient.

This is good stuff, y’all.

Because I was so outspoken and passionately against the position NAHC took in the past regarding other issues, I owe it to the Association (and to myself) to be as outspoken and passionate in my support of this lawsuit.

If NAHC asks anything of its members, please cooperate to the best of your ability.  If nothing else, send the board at NAHC responsible for approving the filing of the claim a note of gratitude.  This is one position that NAHC has taken that benefits all agencies, patients, and the Medicare trusts.

I can respect that.

Feb 19

15 Comments

Confined to the Home

Here’s the point of this entire post.  Medicare knows the definition of ‘homebound’.   Medicare states that patients don’t have to be bedridden but there must exist a normal inability to leave the home and that when the patient does leave the home it requires a taxing effort.

As it turns out, most of us and quite a few physicians also know the definition and write it verbatim on visit notes, care plans and face-to-face documents.  When Medicare documentation calls for ‘reason homebound’, they are not asking for their own definition.

So, here’s my way of avoiding those pesky denials related to homebound status and overturning the ones that do get denied.  At the time of admission or recertification document all of the reasons why the patient can’t just up and go and all contributing factors.

These are very incomplete lists but I always try to support homebound status with as many factors as are applicable to the patient.

Absolutes Supporting Reasons
Severe pain with ambulation multiple medications that can impair balance
Safety concerns due to recent hx of multiple falls. multiple meds that can impair judgment
Disoriented to person and place and must be supervised at all times urinary incontinence
Short of breath while talking, eating or repositioning in bed cumbersome assist devices
SaO2 drops to 87 with activity apprehension about leaving home
Unable to ambulate safely s/p hip replacement moderate pain after standing for extended periods
Impaired judgment secondary to psychiatric illness cannot open some doors, drive or use left arm to balance due to splint
High risk of infection due to open wound and compromised immune system. requires considerable effort communicate needs clearly due to residual aphasia and paralysis of dominant hand.

 

Note the difference between the Absolutes and Supporting reasons.  People are not considered confined to the home because of apprehension alone but it adds depth to a complete picture of a patient with severe pain when ambulating.

Patients short of breath while talking or eating who are also incontinent and rely upon an assist device to get to the restroom are at very high risk for falls.

Documenting all assessment findings that contribute to homebound status at least once an episode and then continuing to support these reasons in your visit notes may very well get you paid.

486 Summary Example:  Patient homebound due to hip replacement two weeks ago and cannot walk without another person assisting him with his walker.  He is taking narcotic pain medications which increases his risk for falls and there are steps without a bannister leading to the front door.

The truth is that we all meet Medicare’s definition of homebound status at times.  Isn’t it hard for you to leave the house in the morning?  Surely it is a taxing effort for you to make sure all the kids have their lunch and homework, find your keys, retrieve your cell phone from the litter box where the toddler put it and somehow make it to the car.  If a normal inability does not include four trips to the car and back to house to retrieve forgotten items including the baby, then crazy is the new normal.

Medicare doesn’t care about any of that. They want to know, from a clinical perspective, how the patients meet the criteria they set forth for us in the conditions of participation.  We need to paint a crystal clear picture and not just write enough to meet guidelines.  When you are finished documenting homebound status, there should be no question that the patient cannot and does not leave the home.

If there is a question, go take a second look.  If you cannot elaborate on ‘SOB with exertion’ (as I am after climbing 6 flights of stairs), your patient may very well not be homebound.

Of all the wild excuses for denials lately, this one is not so unreasonable.  We can do this without changing the law, involving physicians, and praying that the grammar police don’t get us.

Good luck.  I am very confident we can take this denial off the table.

Jan 18

8 Comments

Your Rights as a Provider

It is not my desire to create drama but then again, I am not the one who took away your rights as a provider.

Your contract with Medicare is simple.  It states that you are qualified to perform services for home health and hospice patients and Medicare will pay you according to an agreed schedule.  Occasionally, they review clinical records and refuse to pay based on their assessment of your chart.  If you agree with their decision as is sometimes appropriate, so be it.  If you feel as though you disagree with their decision, you can appeal.

Sort of…..

Last week, I heard a rumor started by the National Association of Home Care and Hospice that the ALJ’s weren’t going to be docketing any more cases from home health and hospice providers.  I knew this could not be the case so I emailed Mr. Dombi at NAHC and he responded by sending a scanned copy of a letter from the Chief Administrative Law Judge, Nancy Griswold confirming this complete and utter lunacy.

For those of you who do not work in the world of appeals and do more important things like take care of sick people in their homes, let me explain this to you.

Imagine you did something else for a living.  Humour me and pretend that you are a roofer.  My insurance company who supplies 95 percent of your business  agreed to pay you to put a roof on my house and you did a fine job.   You shingled my home with materials that will withstand a category 5 hurricane and then you sent a bill and my insurance company politely declined to pay it.   Since the services were covered under your contract, the advance Roof Recipient Notice won’t protect you and I am held harmless while enjoying the sound of the rain on my new Cat 5 roof.

You take your complaint to the board of insurance and they tell you that you are right!  You did install at Cat 5 roof on my house but it doesn’t matter.  No payment is forthcoming.  Their reasoning is that in order to begin work, they had you sign a 30 page contract and on page 27, halfway down, it said that in order to be paid, you must initial the bottom of every page of the contract.  You only initialed 15 pages.

You decide the whole world of roofers and contractors has gone crazy and decide to take the insurance company to court.  The problem is there is no judge to hear your case.

So, I get the roof.  You get nothing and you have no rights.  The insurance company who signed a contract agreeing to pay you is sitting pretty with another satisfied customer under a Cat 5 roof and all you can do is work harder and faster to make up for the lost dollars.

That is exactly what is happening with Medicare appeals right now.  Payment is being refused for up to half of all claims at some MACs (e.g. Palmetto GBA, NGS, CGS) and you do not have any right to appeal denials past a certain point.  There is no person that you can talk to and you are completely unsure if anyone is actually looking at your records before rubber stamping  ‘denied’ on your claim. In short, they don’t give a flying flip that you had to pay your nurses or cover supplies.

When I work appeals, most of my work is done with the ALJ in mind.  If it’s good enough for them, it should satisfy the lower levels of appeals but often it does not.  The ALJ is the first human being that you can plead with to be reasonable. Except in desperate and extreme cases, the appeals process ends there.

Ms. Griswold confidently speaks to the increase in the number of denials being appealed but she does not speak at all to the increase in denials that are fully appealable or the rate of denials being overturned by Administrative Law Judges for the first two levels of appeal.   If the first two levels of appeals were performed competently, the workload at the ALJ would naturally fall as a byproduct of efficient, ethical and fair clinical reviews.

She makes a very valid point that the number of cases has increased overwhelming the ALJ’s but instead of addressing the huge percentage of denials that should have never been, she asks for ‘indulgence’.  It’s like pouring salt into a wound.

How dare Ms. Griswold ask for indulgence when almost half of the claims for home health have been denied by some MACs for grammatical errors relating to the F2F encounter documentation?   She wants to thank us in advance even though she has the responsibility to be well aware that her staff is ultimately overwhelmed due to the enormous increase in unfair denials.

I beg for your indulgence when I say that someone in Washington, starting with Ms. Griswold needs to have the courage to stand up for the good providers and quit playing political games with the healthcare needs of our elderly.

According to the HHS website, Ms. Griswold can be reached at:

OMHA Headquarters
1700 N. Moore St., Suite 1800
Arlington, VA 22209

Phone: 703-235-0635;   Fax: 703-235-0700

E-mail: Medicare.Appeals@hhs.gov

Make use of this information.  If you don’t speak up now, you may not be able to later.

Thanks to NAHC for sharing this information freely without regard to membership status. The content and sentiment in this post are mine alone and should not be attributed to NAHC or any other entity or person. 

Oct 8

11 Comments

What Would My Life Be?

 

Dr. Quaid was a phenomenal cardiologist, now retired and indulging in another talent, art.  He has a fondness for John Deere Tractors, a very wry sense of humour and a quiet demeanor.   I haven’t seen him in ages but he used to run and enjoy outdoor adventures and I think he was secretly proud when his daughter was Mickey Mouse at Disney World one summer.  If you live in Baton Rouge, you can see a drawing he did of the graduating class of Episcopal High at Raising Cane’s on South Sherwood.

So, I have an enormous amount of respect for Dr. Quaid and I can honestly say that I like the man.  He is my second favorite cardiologist after Dr. Wall.  Having said that, please take notice that when I described all of his wonderful characteristics, never once did the words, ‘warm’ or ‘fuzzy’ find their way onto your screen.   He is not one of those men that people call a Big Teddy Bear nor is he the go-to guy for small talk or casual conversation.

You need to know this about Dr. Quaid to understand the kind of day I had when I was working in CCU a few years ago.  A patient who happened to be a relative of one of Dr. Quaid’s partners had an urgent need for a pacemaker.  Dr. Quaid drew the short straw and had to install the unit and I was the only nurse with an empty bed.

He was not happy and I was not happy and the entire unit was not real happy but off we went to conquer another case of nagging bradycardia.

With marginal cooperation from the patient, Dr. Quaid began injecting the area with Lidocaine and began in earnest to float the weapon of dysrhythmia destruction down some large vessel towards the heart – I believe they call it a subclavian but then again, I wasn’t the one steering.  As he was doing so, the patient‘expressed some discomfort’ (screamed at Dr. Quaid to stop) and a decision was made to give him more lidocaine.

It was probably one of those cost reducing measures that resulted in the Central Line kit having only syringe in it.  That one, lonely syringe had long been knocked on the floor but I had another syringe Dr. Quaid could use if he did not touch the cap.  I told him this.  “Do NOT touch the cap,” I said loudly and clearly.

He touched the cap which meant I had to tell Dr. Cheerful that he was contaminated.  Worse, there were no size 8 gloves in the cart and he wouldn’t even try on the 7.5’s.

So I went to fetch another pair of  gloves out of the supply room and somehow caught the corner of the sterile field, knocked the clipboard off the sink causing papers to fly everywhere and tripped and fell through the curtain that was affording the patient (but not me) a small measure of dignity.  I got Dr. HugeHands his gloves and then stopped for a brief second to emotionally prepare for my imminent death or worse; that moment when I wished I had assumed room temperature but didn’t.

So, I can’t say I stepped lightly back into the room where  Dr. Quaid was putting my mess in order. I handed him the gloves and waited for that first caustic word but it never came.  Silence.  Utterly loud, screaming silence.

He quietly returned to his task of electrical wiring but I knew he was unhappy.  I’m intuitive that way.   I pretended not to notice and watched the monitor to see when the pacer wire found its way to its final destination.

The silence grew louder until I couldn’t stand it and I blurted out that I had  endured 14 years of ballet lessons in three countries because my Mom thought it would make me more graceful but she was wrong.  I did not tell him about the ballroom dancing taught by nuns, the tennis partners who refuse to play with me unless an ambulance is on standby or the fact that I have been voted most like to die of a closed head injury in yoga during Savasana.  Still not a word from Dr. Quaid.

After three hours or maybe it was only three endlessly long minutes, he stopped in the middle of a tying a suture, made direct and intimidating eye contact with me and said quite simply, “I hate to imagine what your life would have been like without those dance lessons.”

There is a reason why I am telling you this ridiculously long and utterly humiliating account of an incident that happened long ago.

Keep in mind that on more than one occasion, seizure precautions have been implemented as I attempted to dance when I tell you that many of you cannot write for beans.

Remember that I have been described as an arthritic swan by ballet teachers when I point out that some of you cannot string together a grammatically correct sentence to save your life. Its downright sad to see some of you go through your entire vocabulary in one clinical visit note.

That I have twerked by accident during a Waltz should you make you feel better about visit notes that could be used as a poster for an Adult Literacy campaign were it not for the HIPAA Privacy Rule.

The fact is…. some of you simply do not write well and that’s okay.  Apparently, I do not dance very well.  Much to the dismay of others – a whole lot of others – it doesn’t stop me from trying.

If I hurt your feelings and you are ready to quit, don’t.  If you think your computer documentation will solve your problems, get over it.  If you have lived more than three decades and find yourself correcting more than half of your visit notes after review, give up on trying to be a literary presence.  All you really need to do is accurately convey your thoughts on paper and I am going to teach you how.  Remember, Medicare does not pay for grammar and spelling.  There are no Pulitzer prizes for visit note narratives.

Instead of trying harder, working more, adding more drivil to your notes, simply document the following on each and every visit:

  1. A short description of the patient and what they were doing when you got to the home.
  2. A complete assessment including weights.  Note:  in other health care environments, patients with aortic stenosis have very loud heart murmurs and patients with COPD wheeze.  In other words, document your findings – don’t just check the same old boxes you normally check.
  3. A review of all medications against orders.  Document any discrepancies.
  4. Problems assessed on the visit and any events reported since the last visit.
  5. What you did about the problems.

Example:

Patient at table making holiday plans with f’ly member upon arrival.  Med planner reviewed and noted all medications present.  Pill bottles examined and called MD for refills for Metoprolol.  MD office nurse stated meds would be called to Walgreens.  Pt has loud murmur which has been there since admit.  MD verified that pt always has murmur on admission.  Diabetic foot care done by patient while SN watched.  Pt performed foot care with just a little coaching from nurse.  Pts daughter present during visit and she agreed to pick up medications.  Will follow up.

Then write yourself an email or put a note to follow up on your calendar.  Call the daughter who picked up the meds to verify they are in the home and write a case conference that says:  ‘Daughter said she picked up meds from Walgreens.  See visit note of 09/13.’

Compare that to:

Pt was instructed on the significance of attempting to remember if he took medications before taking other meds.

I read that in a chart of a patient with Alzheimer’s Disease.  Medicare paid for a nurse to instruct a patient with Alzheimer’s on the significance of attempting to remember if he took medications before taking other meds.  And you wonder why I am so brutal in my assessment of your documentation.

The truth is that I know you guys.  You work hard, keep patients out of the hospital, make them well and happy and you deserve to be paid – not arrested.  I’ve heard some of the documentation classes.  I’ve read the examples.  Please don’t bore me with those cold, clinical assessments that tell me nothing about the person you are visiting.

Go practice.   Keep it simple.

 

Oct 7

2 Comments

God Bless Tech Support

Click Here for New Inservice designed to help you avoid F2F denials. 

I carefully considered the requests I received from those you who wanted to know if I had the time and ability to provide an inservice on the Face-to-Face document.  The problem is that the expense for travel as well as the practicality of travelling to multiple states presents a daunting challenge.  Obviously, you would pay the travel expenses but who would sit here and write appeals if I were away?

So, like you, I had to embrace the technology available to me and find some way to provide you with the required information at an affordable price in a manner that did not take me away from doing the work at hand.  I went through two online vendors last week and finally settled on one called SkyPrep.  Now, to be certain, these guys aren’t bad at all but like all computer vendors, they have issues.

The biggest issue is that they take weekends off.  So, all weekend long, I converted PowerPoint presentations and uploaded them various different formats for your viewing pleasure.  None of them had any audio included.  So, I spoke louder.  You may notice that as you watch the presentation.

Sometime around Saturday afternoon, I decided I was too far in to back out now in terms of time.  I continued to record, increase my volume, slowly upload, convert files and sort files like a trooper.  By Sunday morning, I was like a pointman in the marines determined to lead this adventure to a victorious ending or at least one where there were no casualties.  By two o’clock Monday morning, I realized I was defeated.

So, I came to the office this morning and the nice people had returned from their weekends off and informed that the FoxFire browswer was not supported.  That would have been relevant information, don’t you think?

But at last, I have a presentation for you that costs what it would cost you to pay for my services for one appeal.  The beauty of this, though, is that hopefully, you can prevent future denials.

I am hopeful that other organizations who are taking this battle to Washington have great success in permanently relaxing the regulations regarding the Face-to-Face encounter.  Meanwhile, take advantage of my experience in appealing these denials and learn what it is Medicare is looking for.  More importantly, check out the actual denials.  They are the real McCoy.  It’s one thing to read the instructions but still another to see how they are implemented.   Also, see for yourself denials that should have never happened and learn why so you can be victorious in your appeals.  I assure you there is no way I can do every appeal that needs to be done!

I hope you take the hour to watch the presentation and gain from our experience.  I was having fun putting it together for a little while and then SkyPrep took the weekend off and ruined my in turn.

Let me know what you think.

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