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Posts from the ‘Documentation’ Category

Apr 13

2 Comments

Compliance is Good Business

In my experience, the greatest barrier to compliance is that it costs money to be compliant.   Compliance plans are cheap compared to turning away referrals that competitors eat up like candy.  Discharging patients when you think you could maybe squeeze one more episode out of them is hard for some people to do.  Marketers working to develop a new referral source are horrified when an admitting nurse turns down a referral because she doesn’t believe they meet Medicare criteria.  There is no doubt about it.  Compliance costs money.

The real question in business is whether or not your investment will show a return.  We all know the businesses who spend far too much money, those that are conservative with their cash and some that are just plain cheap.  The cheap ones will never get it. If you are cheap, you can head on over to Ebay and buy some second hand computers and forget about the rest of this post.  Those that spend far too much money might have already found themselves in a position where their entire operation depends on making use of the gray area which is getting smaller by the minute.  The providers I am talking to are the ones in the middle.  It is hard to get a good provider who has no compliance problems to buy into implementing a compliance plan.  What’s the point?

Here’s the point.

Every day, you sell nursing care and therapy to physicians and other referral sources.  You charge the same amount as your competitor and you cannot offer any discounts, specials or coupons.  You even sell to the same ultimate buyer – Medicare.  You tell the referral source that your agency is the best in the market and that you are trying new and innovative things to keep patients out of the hospital.  You share a donut or a brownie, perhaps and ask about those Cubs even though you hate baseball because you know the referral source loves the Cubs.

Five minutes after you leave, in walks your competitor who says the exact same thing.

Nobody says, ‘Yeah, well we offer mediocre care but we’re no worse than anyone else.’  Even when it’s true nobody says, ‘we suck at what we do but we offer more cash under the table.’  If it really isn’t your day, the doc has a new flat screen delivered to his house or the discharge planner finds a few loose diamonds in the pocket of her scrub jacket after they talk with your competitor.

So, what’s the point of marketing compliance?

Read carefully.  This is important.

You Do Not Sell What You Do.  You Sell Who You Are. 

Is that clear?  The entire healthcare industry has been under what feels like an attack for the past three or so years.  People are running scared.  The FBI is out and about in a big way in the south.  Three physicians in New Orleans involved with a home health agency were raided a couple of weeks ago.  Regardless of the outcome of the FBI raid, no referral source will work with the agency or any of it’s owners/managers again.

Let the FBI be part of your marketing team since they seem to have no desire to go away.  They are not conducting training exercises and there will be casualties.   Work it!

When legitimate referral sources hear about their colleagues getting raided, it does not mean they will no longer have legitimate referrals for ethical home care agencies and hospices.   You need to be ready for their referrals because the providers who are known for their integrity and ethics will be the first ones called.  They are going to choose the one who never breaks the rules, can speak intelligently about the regulations and provide them with substantiated guidance assuring them that what you are asking them to sign meets all known rules and regulations.

Consider the referral you turn away because the patient doesn’t meet hospice guidelines.  Sure your competitor will take it but when you get the chance to explain why you made the decision, a message is delivered that your competitor was operating in reckless disregard of the regulations or maybe just stupidity.  There won’t be too many of those referrals in the future as more docs are having their lives turned upside down because of a relationship with a less than ethical provider.

A compliance plan has other benefits, too.  A soundly implemented compliance plan can distance you from any wrongdoing by a rogue employee.  In other words, if a new hire doesn’t make visits and hands in notes anyway, you can find yourself in a costly situation of returning money to Medicare or you can find yourself arrested.  The deciding factor will be if the employee was working in a culture where effort was made to verify the integrity of the work submitted vs a finding that a rogue employee was part of a culture of fraud.  Ignorance is not an excuse, y’all.  You have an obligation to look for compliance issues.

Compliance Plans

We regularly work with providers who want to establish a culture of compliance.  I find that if the FBI arrives before I do, the motivation is there to do the right thing.  If a compliance plan is just a binder in the corner that looks impressive and compliance training is given with a wink wink nod nod attitude, it is worse than useless.  It can cause more harm to the provider because a reasonable expectation that their employees know how to be compliant has been established and there were no internal audits to identify areas of non-compliance.

We don’t want to work with you if you think implementing compliance looks good in the likely event that you will have company soon.  On the other hand, if you believe like we do that compliance is good business, we can help you.  We feel so strongly about compliance that I’m willing to tell you that a half baked, ugly as home-made compliance plan implemented with full hearted commitment is better than the most expensive and complicated plan ever created that sits on a shelf.

You do not sell what you do.  You sell who you are.

Be the provider that referral sources trust and respect.

Jan 23

4 Comments

MLN Clarification

Jennifer Barker, a dear friend and the administrator at Audubon Home Health knows me well.  She gets that I do not open emails without a compelling reason to do so and she made sure her I opened hers today.  The subject line was:  WTH?!?  If there had been even one more exclamation point, I suspect the email would have opened itself.

Her concern was with the most recent MLN guidance for the Face-to-Face document which was updated with examples on January 15, 2014.  I read it briefly and did not fully understand her concern until I went back to her email.

Before I tell you Jen’s concerns, go look at page 10 and 11 of the MLN guidance. 

Did you see it? 

Jen pointed out that apparently MLN matters doesn’t realize that home health agencies type up the plan of care.  In MLN’s defense, there is a line that states that MD ‘documents’ the face to face encounter on the plan of care but since there is no change in font or color, it appears as though the encounter documentation is part of the original information sent to the MD for signature.

WARNING:  YOU – AS A HOME HEALTH AGENCY OR HOME HEALTH AGENCY EMPLOYEE – MAY NOT CONTRIBUTE TO THE DOCUMENTATION REQUIREMENTS OF THE FACE-TO-FACE ENCOUNTER.

So, I started looking some more.  The MLN matters document mentions a couple of times about the MD dating the signature of the face to face documentation.  Did that change?  Why on page eleven is it necessary for the MD to sign twice?  I’m just curious.  The Medicare Benefit Manual, chapter 7 pertaining to home health states:

The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.

There is certainly nothing at all wrong with a dated signature and by far, two signatures are better than none.  However, do not be misled into thinking that your face-to-face documentation is incorrect if your:

    1. Face-to-face encounter is documented on the plan of care which is signed and dated by the physician (in which case only one signature is required and that signature is dated)
    2. An addendum is attached to the plan of care documenting the the face-to-face encounter which is signed by the physician (a date is not incorrect but is not mandated according to the Benefit Manual).

The note on page 2 of the MLN matters information may contradict the manual although due to the sentence structure, I am not sure what the note actually means.  It reads:

Note: The homebound status of the patient and his/her need for skilled services must be written in a brief narrative, signed by the physician, titled “Home Health Face to Face Encounter”, and dated.  (Exactly what must be dated in that statement?)

Remember, these are the instructions that your referring physicians are receiving.  There is no point in contradicting them as a date will not invalidate the face-to-face documentation.  However, I do not suggest going back for a revision if a face to face encounter document does not have a dated signature.

Hey, I have an idea…..  Let’s focus on taking care of patients next week.  Any ideas of how we can help each other become better nurses?

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. 

Nov 17

2 Comments

That’s a 1040!

Have you ever, you know, just for fun, went perusing the outcomes of your competitors online? Maybe trying to see if they had an advantage over you? Did you notice anything strange about the OASIS questions regarding flu vaccine?

I always do. Like just now, I went to Medicare.com and put in my zip code and pulled an agency beginning with A, B and C. This is what I found:

How often the home health team determined whether patients received a flu shot for the current flu season?


So, the blue bars are for agencies A, B and C. The first yellow bar is the Louisiana average and the second bar is the National Average.

What on earth is wrong with Agency C, you ask? Would it inconvenience them so very much to inquire about a flu shot?

Chances are they did. Remember, these were the first three that I pulled up. The problem lies in the OASIS question that determines this data.

⃞
0

The word, ‘Episode’ may not have been the best choice to describe the period of time under consideration in this question. It is a vastly overused word and maybe someone at the Head OASIS Office should have considered the likelihood of people confusing the ‘episode of care’ with an ‘episode’.

Don’t let this happen to you. Prove to the world that you care about your patients by learning the difference between an episode and an episode of care.

Episode – A 60 day period of time sometimes called a cert period. It can be cut short by death, partial episode payments and a couple of other things.

Episode of Care – an unknown period of time which begins at admission and continues until discharge unless the patient goes into the hospital. If the patient goes into the hospital, the episode of care ends at transfer and a new episode of care begins upon resumption of care.

In the example below which serves as proof that I have no graphics designer on staff, you see two plain old generic episodes separated by a pale blue line on Day 60 if the admit episode. The episodes of care are in the blue boxes. In this case, the first episode of care goes from admit until day ten of the second episode when the patient is transferred to the hospital (70 days). A second episode of care begins on resumption and ends on discharge (45 days). This means that the episode of care could be 180 days if the patient is on service for 3 episodes and has no intervening hospitalization. Alternatively, if a patient is admitted to the hospital twice in the first 6 six weeks after admission, you will have three episodes of care in one generic episode.

episode jpeg

Is that clear as mud?

Patients who were admitted to services after March 30 and discharged before October 1, should have NA checked. If your answer is, ‘No’, it will not figure into the outcomes if the patient received the flu shot from your agency in another episode or received the vaccine from another healthcare provider (Walgreen’s, their MD, etc.) which will be reflected in M1045.

Don’t shoot the messenger. I serve as the translator and obviously nobody asked me before naming the ‘episode of care’ because I would have come up with a different word to describe that period of time that took over a hundred words and a poorly constructed graphic to fully describe.

Remember, nobody likes the flu. Don’t be known as the agency who can’t be bothered to ask about flu shots. This isn’t nearly as hard as it seems but much more confusing than it has to be. Just saying. If you have any questions, please feel free to call the OASIS help desk.

Ket


 

 

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.

 

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