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Posts from the ‘FMRs’ Category

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


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. 

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….

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.

The Gimme’s

There is nothing in the world that I hate to see more than the ‘gimme’s’ – you know those denials that should have never happened.  It is especially painful to see them in documentation that otherwise met all Medicare criteria.  The good news is that these are preventable.

  1. MD failed to date his signature. 
    1. To reduce these denials you do have legal avenues to pursue.  For 485’s, keep a stack of attestations statements at the desk of the employee who receives and or files the orders.  When she notices that a date is missing, instruct her to copy the 485 and bring it to the DON or marketing department for rapid return to the MD.  If you do this as soon as it is received, the MD will remember signing it and will be less likely to refuse to sign.
    2. On all other forms, reverse the Signature and Date lines.  Make the date line stand out. 
    3. Pay a bounty for all undated signatures found in the clinical records.  If your home health aides came in one weekend and found 40 orders without signatures and you paid them $25.00 for each signature, it would still be less than one episode.  Who do you want your money to go to?  Loyal employees or back to CMS after you worked hard for it.
    4. Look into electronic signatures.
  2. Missing documentation
    1. In some patients, a single visit note can downgrade a chart to a LUPA.  Worse, you cannot demonstrate that you followed orders.  If an order is missing for a skill, then the visits for the skills are discounted, as well.
  3. No end in sight for daily visits.
    1. If you are below age 40, you may not be familiar with this reg but it is indeed a regulation.  Any time a patient is seen daily by the nurse for a period of 21 days or longer, there must be an end in sight to skilled care.  The only exception is diabetic patients.  Consider a patient that requires daily wound care and you provide it every day for 60 days don’t get paid for it.  You’re looking at a denial of 8k to 10k.  That’s a lot of consulting hours that you could have received from us.
  4. Face to Face Documentation
    1. Write a letter to all of your physicians explaining very clearly this condition of payment.  Furthermore, advise the MDs that you are aware of other agencies who do complete the Face to Face documentation for their signatures and in doing so, the docs may be unwittingly participating in Medicare fraud. 
    2. For physicians who have been late and uncooperative with face to face documentation, send someone to the MD’s office with a blank form at the time of the next referral and wait for it to be completed and signed before admitting the patient.  If it takes too long, start practicing the violin or, if you are an accomplished violinist, the tuba.
    3. If an MD has not returned the form and you have no other independent verification that the visit was made, prepare an HHABN for the patient and discharge them.  Explain to the patient that they absolutely can continue home health care services but they will be responsible for payment as their physician has not met the Medicare Conditions for Payment.
    4. If there is independent verification that the visit was made – written instructions, a copy of a prescription, etc., turn it over to the agency administrator.  On admit, look for these things!
    5. Do NOT become violent with the MD.  Legislation is being introduced in several states that will relax the penalties for Doctocide if lack of Face to Face documentation is used as a defense but thus far none of the new laws have been implemented. 
  5. Unlicensed Staff
    1. This happens very rarely but it is a nightmare when it does.   If you find out that a physician was not licensed in your state and your state did not allow physicians from other states to sign orders, every patient you have admitted to that doc is unbillable.  Worse, state Medical Practice acts vary.  Do not assume that because you did something in VA that it is okay to do in Montana.  Look it up.
    2. Similarly, Registered Nurses and Therapists who admit patients and have allowed their license to lapse have created documentation which determined an episode payment that is not billable. 
    3. This happens so rarely but when it does, it can cause total devastation to an agency.  Worse, it is usually not an oversight but a nurse or MD who has not disclosed that their license has been revoked.  This is easy to fix by having all of your clinical staff run and print their own licensure verification at the beginning of each quarter.  Hold their patients if they do not comply.  Get the office to verify MD’s every 3rd referral or once a month, etc.

Effective this year or maybe last, (who knows anymore with all the changes in health care), any provider who receives money from Medicare in error has sixty days to return it.  Failure to do so will elevate that erroneous claim to the status of a ‘false claim’ and the penalty is triple the amount of the original claim.

I hate the Gimme’s but if I worked for  Palmetto or one of the other MACs I would love them.  Once an undated signature is found, reviewing the rest of the chart becomes unnecessary.  On to the next.  But remember, I hate the denials resulting from a ‘Gimme’ but not as much as the agencies who end up on focused review because of the Gimmes or the owners who must have that conversation about trade school vs college with their kids.

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