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Posts from the ‘Documentation’ Category

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.

Sep 8

1 Comment

A Gross Distortion of Truth

Implemented in 2011 as part of the ACA, the Face-to-Face requirement was mandated as a way to prevent Medicare fraud.  Well known cases of fraud involved agencies paying physicians who have never seen a patient to sign orders.  The best known case is that of Jacques Roy in Texas who defrauded the government of 450M by running an orders signing factory. There are more cases like this but these agencies are in the minority.  Although it is inconvenient at times, it should not be too difficult to satisfy this requirement to prevent additional fraud and abuse.

    1. The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.
    2. 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.
    3. It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.
    4. It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

I received a copy of a face-to-face document last week and posted it below.  This patient has Parkinson’s disease, congestive heart failure and chronic pain.

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As many of you can guess, it was denied.  Nobody doubts that the patient was eligible for services or that the services provided were reasonable and necessary.  The physician saw the patient on the 26th as indicated in the documentation and also daily while he was hospitalized.  Physical therapy was indicated as the reason for services in a section of the document I could not clip without revealing personal health care information.

So why was payment denied for this patient who met eligibility requirements and received much needed covered services?  The physician did  not write a ‘narrative’ because the silly doctor thought it was self evident why someone with diagnoses of pain, Parkinson’s Disease, congestive heart failure who kept falling despite use of an assist device was confined to the home.

This particular document was appealed recently so it was easy to find but I have scores of them in my computer from numerous clients from all over.  And most will be denied.

Medicare states:

The face to face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

Nobody could possibly have more knowledge of the above patient’s condition than the physician who saw the patient daily in the hospital and then signed a face to face document.  Shame on that physician for failing to use verbs and pretty language to describe the patient better.  Perhaps he thought the document to which the face-to-face encounter was attached would be read.  Wrongo.  As with all statutory denials, the work is over when the claim is denied.  Why take your time to read an entire chart or even the care plan if the claim does not meet billing requirements.

Adding to this are the thousands of face to face encounters that meet all requirements and are denied regardless.  When this happens, an appeal is sent to the QIC (the next level of appeal) and often the QIC finds that the face to face encounter did satisfy all requirements but another reason for denial is found.  This tactic essentially robs the agency of one level of the appeals process.  

After working in post acute care for all these years, my faith lies in home health and hospice.  We have not lived up to our potential as a sub segment of the industry, but we are getting closer every day.  It will be a moot point when congress and other policy makers hear information painting a picture of our industry as blatantly fraudulent and unable to follow even the simplest regulation designed to prevent fraud.  That is my concern.  We will be somehow be left behind as new budgets are developed and our reputation is tarnished.

And to this day, I believe that if we did live up to our potential, congress would be lining up to ask how we wanted to be paid instead of  dismissing us as criminals in scrubs.  We will never live up to our potential as long as education, consulting, inservicing budgets are dedicated to teaching nurses how to review the face to face document to fund payroll.

Most importantly, I want copies of all face to face documents that have been denied if you don’t mind sharing.  You can sanitize them by removing personal health information or I can send you a HIPAA agreement so you can send them as is.

I am losing faith that our government, the one who wants to control 20 percent of our economy with the ACA is being truthful when they state that the purpose of the face-to-face encounter is to combat fraud.  Color me cynical but I see it being bastardized as a way to deny providers payment for covered services rendered to eligible providers. 

 

Aug 4

Face to Face–Your Results

A few weeks ago, you were invited to take a quiz on the home health requirement for face – to – face encounter documentation.  If you haven’t already done so, please go take the quiz now.

The results were interesting to say the least.  You know when a face to face encounter must be done and you are very clear about your (non) role in the creation of the document.  Where you fell off was in the questions regarding who signs the face-to-face document.  If your overall score was not what you hoped, rest assured that your colleagues are right there with you.

Here are some of the more interesting responses.

Less than 50 percent of you knew that if a patient died prior to the 30th day and a good faith effort was made for the patient to have a face-to-face encounter, you may still bill.  This is not a suggestion regarding how to get around those pesky MD’s who refuse to sign, by the way.

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The question that was particularly disturbing was a true/false question inquiring if it was true that the same physician who signed the 485 must also sign the face-to-face encounter document.  If you answered that question correctly, you are among a 35 percent minority.  A full 65 percent of you answered it incorrectly. (Green is good, pink is bad – I did not choose the color scheme.)

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Similarly, less than half of you knew that if the hospital documentation was used as the face-t0-face encounter it had to be labeled as such and the date of the encounter had to be included.  When you consider many of the discharge summaries, they often apply to the entire hospital stay.  A visit date must be identified and declared as THE day the encounter occurred.  image

Rest assured, other than these very three common reasons for denial, y’all knew your stuff very well. 

So what do these results mean? If I was paid by your agency to come in and teach y’all about the face to face encounter and after I left, you continued to get denied, would you consider me to be an effective teacher?

The truth is that Palmetto GBA is responsible for educating you on the face-to-face to requirements.  This is part of their contract with CMS. 

Here’s the part that keeps up at night.  If all of you were to learn exactly what a perfect face to face documents looks like and then you all taught ten people who in turn taught ten people, by the end of next week literally billions of people would know everything there is to know about the face to face document. 

And not one patient would receive better care because the physician forgot to label the hospital documents as the face-to-face document. 

Just sayin…  Palmetto GBA, take it for what it is worth but I respectfully suggest you might have a little more work to do in the realm of face-to-face document denials. 

Jun 13

4 Comments

Battle Scarred

war against fraud

Normally, I try not to be so very outwardly hostile towards CMS but lately, it seems as though the feds don’t really need to justify intruding on my privacy or the bank accounts of legitimate health care providers, so, whatever. The fact is that the face to face document has become the equivalent of a Weapon of Mass Destruction by CMS and their contractors.

You, as a provider, have a lot to lose if you do not honor the provider agreement signed with Medicare.  What everyone forgets is that Medicare signed the very same agreement which guaranteed you payment for rendering skilled care to eligible beneficiaries.

Rightly and wrongly, Palmetto GBA has been denying claims for months with no consideration of the care provided to patients.   This week, CGS announced it planned to follow in the footsteps of PGBA which will radically increase denials for those providers.

The abuse of the Face to Face requirement by CMS contractors has gotten so out of hand that it has become abundantly clear that they are looking for any reason to deny providers regardless of the care that eligible beneficiaries received.

To be clear, there have been agencies who paid a medical director to sign orders blindly for the sake of convenience.  There are other physicians, like Dr. Jacques Roy who sold his signature and his soul for money.  The intent of the document was to ensure that patients were seen by their physicians who were then willing to sign their name to a document stating the patient needed care and was homebound.

So the rationale was sound and initially, it was not much more than an inconvenience for agencies to get an additional document signed upon admission.  Beginning last year, the face to face requirement has been bastardized as a weak excuse to hold onto money that good providers earned providing skilled care to eligible beneficiaries.

There is not a day that goes by that I don’t hear from someone about a denial related to face to face document and more importantly, it is rare that a day goes by that I am not made aware of very real fraud.

I have no idea why Palmetto and CGS have decided to wage a campaign of hostility towards providers.   In the ‘good old days’ when FMR was about the worst thing that could happen to an agency, the solution was simple.  Document well and follow the guidelines.  Lately it doesn’t seem to matter how good or bad your chart is.

One physician wrote in the reason homebound section, the ICD-9 codes for Parkinson’s Disease and scribbled ORIF.  I get that the document did not meet all the requirements for a narrative.  Also included on the document was the patient’s age (85), the fact that he had PEG orders.  Perhaps I am reading too much into the information.  Maybe it is reasonable to believe that an 85 year old patient with Parkinson’s Disease, and a hip replacement could leave the house unattended to play bingo.   Or softball.

Another physician wrote the reason for home health was paralysis.  Skilled nursing was ordered for catheter care and so the claim was denied.  The MD did not realize the nuances of home health coding apparently and the claim was denied because we can’t fix paralysis.

We can’t fix lazy and stupid, either.   It certainly relieves Medicare contractors of the burden of reviewing records if a face to face is not completely accurate or grammatically correct and it has become abundantly clear that many of the records sent are not even read.

The sophistication of the Medicare IT has grown exponentially in recent years.  They are able to tell if the physician who signed the 485 is not listed as the patient’s physician in the database but they cannot see a Part B claim from a physician and determine that the patient was seen timely.  Do they really believe that all those patients admitted from the hospital were not seen by a physician?

Not one single Medicare beneficiary has received better care because of this insane demand on agencies.  In fact, time and resources that could be used to teach nurses about the new Diabetic protocols (bet you didn’t know they were published) or otherwise enhance the clinical skills of nurses are being devoted to getting the physician to document one encounter multiple times to ensure the agency gets paid.  In some cases, the agencies are simply completing the form for the physician’s signature.  They get paid.

I strongly encourage you to play by the rules but also to fight every single denial for a face to face to the level of an ALJ.  The days when the cost of appeal was taken into consideration when determining whether or not to fight it are now part of our rich home health history.  Fight everything until an ALJ or two sees how very abusive these practices are.

Don’t call or email me for a couple of weeks if you have something confidential to say.  I figure after about two weeks, the feds will see how very boring my life is and remove the wire taps. And try to find some time in between ADRs and running down face to face documents to, you know, take care of a patient or two.  Remember them?  Patients?  Elderly, lots of DME and a ton of pill bottles; none of which contain the pill she thinks she takes for sugar.

Please tell us about any face to face horror stories below or email them to me privately.  If you are a client and anyone asks who your consultant is, tell them Jnon Griffin or Lisa Selman Holman.  Just sayin….

Jun 3

4 Comments

The Discovery Process

blogI like to read courtroom dramas in my spare time.  I especially like the ones where the nobody lawyer gets a case that he cannot possibly win but his client is innocent, and then against all odds, like Rocky of the courtroom, the small town lawyer wins the case.

These books are not completely without educational merit.  I have learned all about the discovery process, for instance.  Get this – when one side asks the other for evidence, they have to hand it over – just like ADRs.  Obviously, there are prosecutors all over these dime store paperbacks that do not want to show their hand to the defendant but the law is the law, right?

Here’s the educational piece.  What happens is that when one side is compelled to turn over a document to the other side and they really don’t want them to see it, they put it in a box with thousands of other documents.

Some of you already knew that, didn’t you?  I know that because I read your documentation.

Here’s an actual set of goals from an otherwise excellent chart.  Note there is nothing horrible about these goals but work with me, folks.

    1. The patient will have no hospitalizations during the episode.
    2. Patient will have absence or control of pain as evidenced by optimal mobility and activity necessary for functioning and performing ADLs by the end of the episode.
    3. Patient skin integrity will remain intact during this episode.
    4. Patient will be free from signs and symptoms of respiratory distress during the episode.
    5. The Patient/Caregiver will verbalize and demonstrate edema-relieving measures by end of episode
    6. Patient will maintain low na+ diet compliance during the episode.
    7. Patient will have increased mobility, self care, endurance, ROM and decreased pain by the end of the episode.
    8. The patient will be free from falls during the episode.
    9. The patient will be free from injury during the episode.
    10. Patient will remain free of adverse medication reactions during the episode.
    11. The Patient/Caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by end of episode.

Now, take the painful journey with me starting at the first goal.  Whether or not the patient is hospitalized is not a stand alone actionable goal.  Sure, you could lock the patient in the closet but the real goal isn’t to keep them out of the hospital.  That’s a lie Medicare told us to save  money.  The real goal is to keep them from requiring inpatient care.  You accomplish that outcome by creating patient specific goals relative to the identified risks of the patient and following through with interventions crafted to meet those goals.  (Obviously, I have been doing too much Joint Commission work lately.  What I meant to say is you keep the patient out of the hospital by taking care of the problems that might land him inpatient somewhere.)

Moving right along, without violating any HIPAA regs, let me just state that the patient had no pain upon admission, no pain medication ordered except prn Advil which was rarely taken and no reason to think she would get pain.  More importantly, it would be unreasonable to think that lowering her pain level from zero would in any way, shape or form lead to optimal mobility and activity for performance of anything.

The third goal addresses skin integrity.  Note that the nurse wants the patient’s skin integrity to remain intact….  How does that work in a patient who was admitted for cellulitis?

The respiratory distress goal is admirable.  Everyone should remain free of respiratory distress.  This patient is free and clear of respiratory illnesses so it appears as though the goal was just taking up space.   Its kind of like writing the patients heart will beat throughout the episode.

The patient/Caregiver (which caregiver, folks?  The patient lives in in an ALF) verbalizes and demonstrates edema relieving measures.  Wow!   Does that mean the patient will put their feet up while they watch tv?  Does it matter what they verbalize?  I am quite certain that people will say almost anything.  Maybe a better goal would be that the patient had 1+ or less edema throughout the epsiode.  I think it’s kind of lofty to assume the patient with cellulitis to their lower legs will have no edema.

The pt will not eat a lot of salt.  Really?  That’s a goal for a patient who lives in an ALF where her food is prepared by the facility?  Should dietary sodium intake be the focus of care for a patient who is 90 years old and takes a single low dose of blood pressure meds and has no recent exacerbations?

The 7th goal is quite impressive in it’s verbiage but its useless.  How do you reduce zero pain?  I think the 90 year old patent is doing damn good to be in an assisted living facility ambulating with a walker and receiving only intermittent assistance from home health for her cellulitis.

Check out goals numbers 8 and 9.  The patient will not fall and the patient will not be injured.  Unless there is a serious violent crime problem at the ALF, it occurs to me that it might be more efficient to write:  The patient will be free from injuries related to accidents or falls (or gunshot and knife wounds) this episode.  And while a zero tolerance for injuries is an admirable goal, it is important to remember that it is a goal.  Goals are not like wishes.   We must direct care towards them.  How about a little therapy, folks?

The last two goals are about drugs.  The drugs in question are bactrim, thyroid medication, amlodopine and an NSAID for occasional pain.  I think that’s kind of impresssive for a 90 year old.  And while medications are extremely important, I happen to know the ALF has a med program and even without, I think one med goal would be sufficient.

What’s missing?  You didn’t see it did you.  It’s like looking through a box of documents produced as part of discovery.

Where is a goal related to the patient’s cellulitis?

Important Note:

Many of you received my email regarding Southeast Louisiana Home Health and South Louisiana Home Health, Inc.  I mistakenly wrote in a previous post – now removed, that Southeast Louisiana Home Health had a little fraud problem.  I was wrong.  It was the owners of South Louisiana Home Health, Inc. that were indicted for fraud.   The Department of Justice issued this press release where it is clear that the Ages, owners of South Louisiana Home Health, Inc. were the subject of the investigation.  I regret any confusion.

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