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Posts from the ‘coordination of care’ Category

Making Time

It’s lonely being a Director of Nursing – doubly so when the agency Administrator is not a nurse.

There are subtle differences between states on the responsibilities of the Director of Nursing but together with the Clinical Supervisor’s role outlined in the Conditions of Participation, it is clear that a DON is responsible for almost everything that happens in a 200-mile radius.  These responsibilities include but are NOT limited to:

  • Oversight of all clinical personnel and all clinical services
  • Making sure that all patients have care plans
  • Patient Assignments
  • Developing and overseeing clinical policies and procedures
  • Infection Control
  • Quality Assurance
  • Staff education
  • Compliance
  • Hiring staff
  • Ensuring that all admission procedures are followed

That’s a pretty daunting list so I hesitate to say it is incomplete but… it is.  Although the tasks can be delegated the responsibility belongs to the DON alone.  Going to a non-clinical administrator about infection control or required education for staff may be a fun way to spend an afternoon but the surveyors will look to the DON for answers.

Before you quit your job and punch yourself in the face for accepting the responsibilities of the DON position, relax.  It can be handled and is handled every day by nurses who are no more skilled than you.

Like most overwhelming jobs, the position of DON is easier when broken down into smaller pieces.  It is also easier if you identify all the impediments to doing your job well before you try to do it better.

Time Management

  • Open Door Policy – this sounds really good in company sound bites and recruiting campaigns but an open door policy can wreak havoc on your day. Instead, hold office hours like college professors do.  This doesn’t mean that nurses cannot interrupt your day for urgent matters but all non-urgent matters should be conducted during office hours.  During office hours, your visitors should have your full undivided attention.  If you want to make notes, wait until after they leave and write down your thoughts while still fresh in your head.
  • Meetings – Meetings are important but after a point, they become time-wasters. Eliminate all meetings that are not necessary and be prepared for necessary meetings.  Meetings should start on time.  Invite participants to arrive a few minutes early if they want to visit with coworkers.  Clinicians who are unprepared at case conference will be obvious.  Don’t rescue them.  After they flounder in front of their peers once or twice, they will be able to fully participate.  Or not.  If an adult cannot be responsible and prepared for meetings, maybe you should rethink their position in your company.
  • Delegation – most tasks of the DON can be delegated. Delegation consists of two parts – one is assigning the task and the other is the oft forgotten follow up.  Survey is a very bad time to find out that a nurse performing utilization review did not understand the process.   Send yourself an email to follow-up on an assignment you delegated.  Was a nurse tasked with collecting data for infection control?  Write it on your calendar to check in with the nurse in a month.  Look at the work done.  This takes a lot less time than trying to recreate data during a survey.   Taking the time to schedule QA, OASIS transmission, annual advisory board meetings and other infrequent but mandated events will reap an enormous return on investment.
  • Set aside some time each day when the phone does not ring in your office. Have the receptionist screen the calls and take messages.  Only take calls from patients who cannot be helped by their nurse, and referral sources.  When this policy was implemented at one agency, about half of all phone calls were handled before they got to the DON.

Hiring Process

 Learn how to interview potential candidates for a job. Listen to what they have to say.  Monster. com has a list of the 100 Most Asked Job Interview Questions. Consider asking candidates to teach you about falls precautions or injecting insulin as if you were a patient.  (Note:  do not ask about what kind of care they drive as suggested on Monster.  Ask what kind of car they dream about owning.  Avoid candidates who name a grey sedan.)

  • Schedule all interviews on the same day and set a mental timer to reduce the amount of time you spend on each interview.
  • In larger agencies, consider deferring the initial interview to a case manager who will be the direct supervisor of the new employee.
  • In all agencies, schedule a second interview that includes various people the candidate will work with on a daily basis. Your current staff is more likely to support a new employee if they endorsed the initial hire.

Staff Education

  • Get someone else to provide education to your staff. Call on drug reps to teach your staff about new and trendy drugs.    Get the wound care folks to teach about wounds.
  • Involve staff by assigning a five to ten-minute presentation on compliant documentation, a new drug or a condition not seen very often in your area to begin each case conference. (Note:  You can start to identify the next case managers or even your replacement by observing how well prepared they are and how comfortable they are talking to their peers.)

Perks of Managers

Setting up your work environment to allow for focus and completion of the tasks and follow-up on coworker’s projects will leave you feeling accomplished. Your stress level will automatically decrease as deadlines are no longer looming over you.  Your ability to trust your staff will improve when you follow-up up on their projects allowing you to appreciate the support you have.   Most importantly, you’ll get home in time for dinner with the fam.

Got any other ideas?  Post in comments!

Personal Care Services

Who else do you know that has been assaulted by one personal care attendant and threatened (as recently as an hour ago) by another?  None of this had anything to do with work.  I could tell you stories for days but I want this uploaded to the internet soon in case I unexpectedly die.  I want you to read it so that you can look a little harder at the personal care attendants taking care of your patients.

Let me start by saying that some of the most wonderful caregivers in the world are PCA’s.  They have saved more lives than we’ll ever know simply by alleviating loneliness, keeping our elderly safe in the home and making sure they are properly nourished.  You couldn’t count the number of broken hips, bedsores, falls, infections and accidents they have prevented.  A personal care attendant can prevent nursing home placement which many elderly people fear and become part of the family.  The majority of PCA’s are give more than they take.

There are other personal care attendants and companies who are no more useful to society than your run of the mill crack whore.  Consider the following cases:

  • Numerous indictments have been obtained because personal care assistants continued to bill for patients who had moved out-of-state
  • Countless hours have been billed fraudulently.  Many times, the PCA’s do not meet minimum employment standards.
  • Others continued to bill when patients were in hospitals and nursing homes.
  • A PCA boyfriend billed for providing personal care to his girlfriend while she was in jail.  The girlfriend got mad and turned her boyfriend in when he would not use the fraudulently obtained Medicaid money for bail her out of jail.
  • According to an indictment which has not gone to court yet, a beneficiary got out of jail for a one day furlough to meet with his case worker at home so he could continue receiving Personal Care Services. Allegedly, he was approved for the services and then returned to jail while Medicaid continued to foot the bill.
  • A personal care attendant admitted to forging  a personal check in the amount $10,000.00 from her patient’s personal checking account.  She then deposited it into her mother’s account.  The check did not clear.  This is almost forgivable.  There must be a diagnosis that prevented her from understanding how bank checks worked.
  • A New York provider will be paying back over 2M because they billed for services not rendered and inflated hours on billing.

This paints a pretty bleak picture of the personal care industry.  Keep in mind that there are no OIG press releases about legitimate companies who provide excellent care.

What can you do?

  • If you are discharging your patient to PCS services after skilled care is no longer needed, try to overlap a week or so if your state allows it.  You can spend some time training the PCS on the proper way to care for your patient’s unique needs.
  • If your patient has personal care services established when you admit the patient, check up on them.  In the situations where I have been threatened it was because a friend who was afraid to talk to the aide was eager to talk to me.  Ask direct questions about the quality of care and the level of satisfaction.  Pay attention to both what the patient says and doesn’t say.
  • Ask to view the home folder.  Call the PCS company and speak with the RN responsible for creating and overseeing the plan of care for the home worker.  To coordinate care, there should be a copy of the most recent care plan in the home.
  • Review the home folder for accurate contact and grievance information.  Verify the phone numbers and the name of the owner/Director of Nursing.  Write the number in large print for your patient to see.
  • If you frequently find your patient alone, ask about the home worker’s hours and care plan.  Check the time sheets if they are kept in the home binder.

The OIG looks a lot at the dollars spent on fraudulent visits.  Medicaid costs for personal care services in 2011 totaled $12.7 billion, a thirty five percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018.

We should look more at the care given to our patients.  In most cases, people who are willing to commit fraud are not overly committed to the wellbeing of their patients.  There is no shortage of personal care attendants looking for work and some of them are very competent and dedicated to their patients.

If you’re thinking this is not your job, I beg to differ.  You have a responsibility to ensure that caregivers, paid or unpaid, are responsible and capable.  Remember you are a mandated reporter of abuse and neglect.  Coordination of care is a Condition of Participation for all Medicare Providers.  More importantly, it is one of the underlying principles of sound clinical practice.

The last threatening phone call I got was a little while ago.  If this ends up being the last post I write, it was good knowing you but don’t lose any sleep fretting about me.  I am too stupid to be afraid and that tends to confuse people who mean to harm me.

When Harm in the Hospital Follows You Home is an award winning group of journalists who write stories they want to write because they need to be heard.  They allow pretty much anyone to republish their articles at no cost and do not accept any money for advertising.  They have done a terrific job of covering nursing homes in the past and they are paying very close attention to harm caused to patients as the result of medical error in the hospital.

We get these patients –  from referral sources at times.  As nurses, We are understandably very sensitive to our colleagues and are fully aware that our patients do not understand the way things work and often disregard their complaints of our colleagues.  The very last thing we want to do is cast dispersions on physicians we know and respect.  Even when we don’t particularly like or respect a physician, there is always that nagging fear of repercussion if we do speak out.

Our job is not be judge and jury.  We cannot begin to go back and determine if the patient suffered an error in the hospital.  That is one of the reasons why this interview from Probublica with Dr. Gerald Monk, a professor at San Diego State  University caught my attention.  He brings light to the very real trauma patients experience and how, in some instances, we can make it worse by pretending that nothing really happened or disregarding their feelings – whether they are based on real circumstances or a misunderstanding.

One million patient’s y’all.   That’s a ton of damage to the people entrusted to our care.  We can continue to ignore it or we can work to heal patients both emotionally and physically.  Enjoy the article and let me know what you think.  Check out the facebook page as well.


When Harm in the Hospital Follows You Home

by Olga Pierce ProPublica, March 21, 2013, 2:30 p.m.

“How is it possible to move past medical harm when every single aspect of life is impacted by it ” when absolutely everything a person believed about doctors, lawyers, oversight agencies, insurance companies is turned upside down and inside out?”  Robin Karr, patient harm survivor

A slip of the scalpel, an invisible microbe, a minute miscalculation. It’s estimated that something goes wrong for more than one million people per year during a visit to the hospital. Some patients experience a full physical recovery. Some are never fully healed.

But even if patients are lucky enough to physically heal, their lives may never be the same. Sleep becomes elusive, relationships break apart, and a wall of silence appears between patients and the doctors they trusted.

What follows is a conversation of sorts between some of the 1,550 members of our ProPublica Patient Harm Facebook community and Dr. Gerald Monk, a professor at San Diego State University who specializes in dealing with the aftermath of patient harm for both patients and providers. We asked group members to share their questions and thoughts about the aftermath of patient harm, and then got Monk’s response. What emerges is a portrait of the long journey that begins after the unthinkable happens.

Monk’s comments are not a substitute for treatment by a mental health professional. They have been edited for clarity and length. Each quote in italics comes from a member of ProPublica’s Patient Harm Facebook group.

PP: What symptoms can survivors of patient harm expect?

“I find I think about what happened day and night.”   KariAnn Syna 

“Survivors have “very real PTSD symptoms, including avoidance, difficulty sleeping, etc.” Debra Van Putten

“I experience ‘flashbacks.'”  Georjean Parrish

Dr. Monk: The psychological symptoms are similar to those people suffer when exposed to physical, sexual and psychological violence. What all these things have in common is that they take place in settings where we reasonably anticipate that we will be safe and secure. We tend to believe the maxim that the doctor will do no harm.

The symptoms can be physical, such as headaches and sleeplessness; or psychological, like depression, anger, guilt and being vulnerable to drug abuse.  Patients can even blame themselves. A survivor of harm surely knows others that have had the same medical procedure without suffering harm, and so they can feel they somehow contributed to the error because they were at the wrong place at the wrong time with the wrong health care provider.

PP: Many group members expressed feelings of betrayal by the health professionals and authorities they thought were there to protect them. What phenomenon are they experiencing?

 “A patient who is denied validation for their medical injury is betrayed by the medical system they have learned to trust as an official authority. It is a shocking experience to realize that everyone one has thought about trusting this authority is suddenly wrong.” Garrick Sitongia

Dr. Monk: Patients can feel especially violated in the context of health care. Not only do patients anticipate being safe and secure, they expect to be healed. Following an adverse medical event, a patient may experience a lifetime of heartbreaking anguish and suffering.

PP: Group members describe a related problem. Others are reluctant to hear their new understanding of the health care system and dismiss them as crazy or tell them “it’s all in your mind.”

Dr. Monk: Doctors are trained to be perfectionists. They are expected to answer difficult heath care problems and to know how to heal. Sometimes doctors are also pressured to gain legitimacy by exuding a sense of confidence and certainty when they don’t actually know how to make a patient well.

As we know, the reality is that health care is far from perfect. Medicine is inexact yet doctors face the expectation that they will fully understand the human condition and know all of the complexities about what ails us.

This is an onerous responsibility, and this territory can be ripe for misunderstanding between health care providers and the patient and family members. Doctors may feel that patients haven’t communicated all of their symptoms or followed through on their instructions, and this can leave patients and their families feeling blamed.

PP: Many patients say they encounter a ‘wall of silence,’ where providers are unwilling to discuss what happened and which hinders the healing process.

“There can be a “refusal of anyone to talk about the emotional impact or an error on both the provider, care team, patient, and their family … it feels like a systems error ends up being an individual problem and no one wins.” Sherry Reynolds 

Dr. Monk: The health care environment is still dominated by the culture of “deny and defend.” Most physicians have been trained not to apologize when things go wrong and warned by their mentors that it can lead to a lawsuit. Actually, the opposite is true. Harmed patients who do not receive an apology and an open and transparent investigation about what went wrong are often left with a strong desire for justice. These feelings of injustice drive them toward a lawsuit.

But legal action can make things worse for the patient. It seldom produces any sense of justice and healing and often leads to even more trauma. In contrast, an open and heartfelt acknowledgment of an actual or perceived medical error could lead to psychological healing.

Another distressing part of this “deny and defend” culture is that many doctors and nurses actually want to apologize when things have gone wrong. Many providers went into medicine because they want to be healers and bring good to people’s lives. When things go wrong, it can have catastrophic consequences for providers. They often suffer what is called 2018second survivor’ syndrome. They are traumatized by causing the patient harm and they are isolated and trapped with secret knowledge about what really happened.

Providers are often called the “second victim” in cases of patient harm, and struggle to handle deep feelings of guilt and remorse.

Fortunately, a growing trend is changing the culture of deny and defend. For example, large health care systems within California, Illinois, Maryland, Missouri, Massachusetts, and Virginia are trying to overcome the barriers in the health care environment to open, honest disclosures and encourage apologies when things go wrong. Some doctors are doing the same: disclosing medical errors and making heartfelt apologies. These conversations can be restorative for providers, patients and their families.

PP: Survivors of harm also describe themselves as isolated from their families just when they need them the most. Sometimes loved ones have trouble coping with the damage, other times they don’t understand why the victim of harm can’t 2018just move on.’

“My husband never doubted me, but the challenges financially, physically and emotionally after suffering irreparable damage by my former dentist 2026 destroyed our happiness … He and I separated.”  Tina Gomes

“I have no family now due to what was done to me … This has proven to be too traumatic for my family to endure so I find myself with no family and no support. It’s as if I’m dead.”  Robin Karr

Dr. Monk: The harmed patient can become frozen with unprocessed emotional trauma following the harm they suffered. They can become stuck in emotional distress and psychological fragility. Loved ones and friends may become exhausted by the victim’s ongoing anguish. They may start to recoil from hearing any more about this ugly situation.

Significant others can feel powerless to do anything other than encourage the harmed party to go to court or stay with a legal process. That can take more than five years, cause significant financial strain, and many cases are decided in favor of the health care professional. This contributes to the paralysis for the family and the harmed patient. These powerful stressors often lead to separation, divorce and alienation of family members.

PP: The feelings of isolation or abandonment are not necessarily limited to friends and family. Many social relationships can be strained, and survivors can feel shunned.

“We went from being the perfect family to being seen as the Addams family. When you have a child die from 100 percent medical error you become every mother’s worst nightmare … It is a grief and pain most people, fortunately, can never understand and are afraid to come near.” – Lenore Alexander

Dr. Monk: There are no societal rituals about how to grieve the losses that come from serious medical error in a socially acceptable way.

While people can be kind and compassionate in their efforts to help, eventually there may be a growing sense that 2018enough is enough’ and survivors need to put this behind them and move on with their lives.

When family and friends tell the survivor of patient harm to move on, or suggest they are psychologically unwell, this can add feelings of shame and guilt to the grief they already feel, which may actually make the healing process longer.

PP: In addition to emotional trauma, there may also be lasting health effects that drag on for years or even permanently.

“How do you ever move on, when you live in a damaged body that reminds you every minute of every day what you lived through?” – Georjean Parrish

“I try to cover up my now ugly body with nice clothes…my body looks deformed.” – KariAnn Syna

Dr. Monk: For a few people there is a form of loss and grief caused by a grievous physical injury that seems to take over a person’s whole being. Physical prowess and attractiveness can be an important part of how people define themselves. Day-to-day physical injuries and impairments caused by a medical error remind victims of what they no longer have in strength, mobility, being pain free and physical appearance.

Some survivors know their body has been harmed forever but they still can’t believe it. Time is moving along but they are not. Yearning for the life they had before the trauma, thoughts and images of the person they once were frequently fill their mind.

PP: Some survivors find the struggle to find acceptance or forgiveness an impediment to moving on with their lives.

“It took until I was finally diagnosed and two surgeries later to even begin to be able to ‘let go’ and ‘forgive.’ After I got Medicare and could go to doctors … who listened and understood, I could begin to be grateful and that’s when healing starts.” – Anna Gardiner

“A big problem is one of acceptance.” How do harmed patients separate accepting their damaged selves from feeling like they are saying that what happened to them was acceptable?” – Jeri Tresler

Dr. Monk: The desire for revenge can be a common reaction among patients who have survived a terrible medical error or for families who have had a loved one die because of a medical mistake. This is compounded when the expected legal punishment falls far short of expectations.

Survivors of serious medical error can feel shocked and horrified by the intensity of their own vengeful impulses when they have recovered sufficiently to have those feelings. They may even withdraw from community support because they feel ashamed of wanting revenge.

In many Western cultures, the desire for vengeance is taboo, and society instead pressures victims of harm to “turn the other cheek” and forgive the perpetrator. But misplaced efforts to encourage forgiveness before the victim is ready can just cause more shame and distress.

Victims of an error need somebody who can acknowledge, accept and support them around intense displays of emotion and not withdraw from them but rather step toward them.  Harmed patients at this time can benefit from working with a counselor who is not frightened by powerful feelings of rage, and revenge.

Counselors trained in dealing with trauma can help survivors speak openly about their experiences without being brushed aside or have the topic changed. This helps a harmed patient begin their own emotional repair. An overarching desire for many harmed patients is to want to move beyond the terrible emotional scars that may accompany the physical ones. Physical injuries may never be healed. Thankfully, with qualified help, emotional injuries can be.

Illustrations by Marina Luz

Exploring Patient Harm: Have you been affected by patient harm? Join our Patient Harm Community on Facebook to share your experience with patients, family members and others affected, or tell our reporters your story by completing our patient safety survey.


When Outcomes aren’t Good Enough

nevada-nursing-licenseSo, I have looked at charts for close to ten different agencies in the past month or so for various and sundry reasons.  Two stood out for me in a way you should think about if you give me a minute.

Both charts involved psychiatric patients living in a congregate living situation with paid caregivers.  They lived in different states and the living situations were different but the similarities are there, nonetheless which is why the second chart caught my attention.

In both instances, there was a ten day gap between the last visit and the time the patient went to the hospital and yet the schedules called for weekly visits.  There were indications that it was not safe to push the visit back and possibly even a PRN visit should have been made.  Both agencies – completely unrelated – had a policy that supervisors should be notified of missed visits and neither nurse followed the policy.

One nurse will stand before the board in defense of a nursing license and the other one will be scolded by yours truly.

The difference is not that one nurse took better care of the patient or that the patient’s condition was any better in one patient than in the other.  The difference was dumb luck.

One patient died from a subdural hematoma.  The other was treated and went back to the facility.  The questions I have are:

  • Did the nurses in each instance visit patients according to when it is convenient for them?
  • If they were employed at a hospital, would they work whichever shift they chose?
  • If a patient really doesn’t need to be seen but once every ten days or so, why not schedule the patient for every ten days?
  • Could either nurse have picked up on something that may have prevented the hospitalizations?

Honestly, I don’t know.  In fact, I sort of doubt it but who knows?  And I am not the only one asking these questions.

In 15 years of of ICU work, I saw a lot of patients die.  It never, ever felt right when a full code patient died on my watch.  The sleepless nights, the endless record reviews, the self doubt all take a toll.  After a while it got better because the brutal questions I asked myself are worse than any a malpractice attorney could ask.  And honestly, not all of the answers were in my favor.  I have made pretty much every mistake there is to make but luckily, nobody died because of them.

The nurse whose patient died will have a lot of questions that will never be answered because an assessment wasn’t made for ten days prior to the hospitalization.  My deepest sympathies lie with that nurse.

What can you take away from this?  Both nurses are guilty of exactly the same thing.   Both put off a visit until later in the week, neither one called a supervisor and the polices of both agencies were ignored. Each situation had a radically different outcome which was likely beyond their control.  Whether or not they saw their patients or notified their supervisor when they did not see the patients was clearly within their control.

Don’t be the subject of a future post.  Follow your schedule.   It is not a suggestion or a recommendation. It is what is expected of you from your patients, your employer and your state board of nursing.

A Pound of Cure

There are so many agencies out there who honestly believe that they will never come under scrutiny.  Some think they are too small and others think they are too big and most think they do things the right way.  And now they have ADRs and they are not impressed with all my impassioned pleas to do whatever it takes to avoid a denial before ADRs start showing up.  Their ounce of prevention wasn’t quite a full ounce and a pound of cure is needed.

It isn’t a coincidence that the worst charts you have were chosen. The MACs and ZPICs are big brother’s younger siblings they are watching.  But wait, before you fill out the job application for the Taco Bell position, there may be some things you can do to control damage and ethically increase your odds of getting paid.

  1. Send the required information to the address on the ADR.  The number one reason for denial is that no records were submitted.  You may have only a very small chance of getting paid if you send it in but you have no chance of getting paid if it isn’t sent in.
  2. Look closely at MD signatures.  The physician must date his signature.  Your date stamp will not suffice to ensure that care plans were in the agency prior to billing.  If you find an undated signature, complete an Attestation form and hopefully the physician will have some record of when it was signed in his office.  An attestation form is a simple form that basically says the MD will get warts on his or her thighs, suffer from weeping eczema and learn all about same sex marriages in prison if the information on the form is untrue.  What you should NEVER do is write a date next to the physician’s signature.
  3. Look at the Start of Care date.  If it is older than 4 months, you better hope that the patient fell down the stairs prior to the episode in question.  If not, call every practitioner who saw the patient during that period of time and ask for copies of all lab and clinic notes to see if you can find something there.  If the patient allows, you can call their pharmacy and see if there were any meds ordered.
  4. Look at Homebound documentation.  Review the functional and neurological status of the patient and determine if the patient’s documentation supports that the patient is homebound.  If the only functional limitation he or she has is the need for a cane and they have no cognitive deficits, it begs the question of why the patient is homebound.
  5. Write a cover letter.  Include a detailed synopsis of why you believe the patient meets criteria for payment.  Homebound may be vague so tie it together.  Use big words like, ‘the patient is dependent upon cumbersome assist devices for ambulation and suffers frequent pain, urinary incontinence and poor vision which make it difficult to navigate independently outside of the home environment without assistance at all times.  He has a recent history of falls and takes multiple medications that can cause intermittent cognitive impairment and unsteady gait.  (Or you could say the patient needs a cane, takes Lortab and a sleeping pill and fell over the housecat but where’s the fun in that?
  6. Collect all information that validates the patient’s condition.  Lab for Pernicious anemia may be four months old.  Send it anyway.  If the patient had a CT of the head and they found a suspicious mass six months ago, send it.  Send anything that supports your reports of how ill the patient is.
  7. Write addendums if required.  If your nurse is certain that a particular event occurred but it was not documented, the time to document is NOW.  You should never go back and edit notes that are on the clinical records.  However, you can write a communication stating that effective on 01/01/2012 the patient had a seizure and went to the ER.  There is nothing shady about correcting documentation as long as it is done within ethical guidelines.
  8. Number your pages.  Simple but one problem I continually have is that charts were sent in with interim orders and somehow they are not noticed by the MAC o the ZPICs.  If there are page numbers at the bottom of each page, it is easier to convince whomever is reviewing your clinical records that day.
  9. Keep an exact copy of everything you send.  You have no earthly idea how many people do not do this.
  10. Back out claims for charts that should not have been billed.   If your chart is such that it should have never been billed, send it in anyway. Back out the claim, print the screen and attach it to the ADR documentation.

If you get denied, appeal it if you honestly believe it shouldn’t have been paid.  If it is a flat loser there is still value from the lessons you can learn from the chart.

We do look at ADRs and denials with more frequency than you could imagine lately.  We will be happy to review your records and also write arguments at the appeals level for you.  I must advise you that sending us the chart before you send it to the MAC is probably the best sequence of events.

I’m trusting y’all to keep us posted on what is going on out there.  Call me at 225-253-4876 or email me at my personal email address.