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Posts from the ‘Medicare Cost Reports’ Category

Getting Paid

I see a lot of denials in my job.  Some (actually a lot) are legitimate because the agency hasn’t complied with one or more regulations.  I have also seen an alarming rate of denials that cause me to question the competence of those performing the reviews.

Last week I received a copy of a denial.  It was actually the second denial on the same claim.  Palmetto GBA originally denied the claim as they did not think that the Alzheimer’s patient confined to a wheelchair was homebound.  My client appealed to Maximus who agreed that the patient was in fact, confined to the home but then denied the claim because there was no documentation of the face to face encounter.  The reason my client did not send the documentation is because the episode in question was the second episode and the face to face encounter occurred prior to the first episode.

I am also seeing claims denied because of physician signatures.  In some states, my own included, the signature requirement in the minimum standards reads that if the agency documents when the orders were received by the agency, that will suffice as evidence that orders were received timely according to state minimum standards.

The state does not pay your Medicare Claims.

Medicare requires that the physician both sign and DATE his or her signature.  Failure to do so will result in a denial.

Statutory Denials

Statutory denials are like free spins on the slot machine for the folks who review ADR’s and other claims.  A statutory denial means that the patient was somehow not eligible for services and therefore, nothing is covered.  Compare that to a denial because the reviewer did not think that two of the visits were covered.  If the total number of visits was greater than 6, then the two non-covered visits will not result in a loss to the agency.  If an ICD-9 code is not supported, the payment will be downcoded usually costing the agency a couple of hundred dollars.  But if the patient is not homebound, or there is a problem with the physician, or the orders are not signed, the claim is denied in its entirety and no further effort is required by the person doing the review.

Now, if it were me and y’all can thank your higher power it isn’t, I would go for the statutory denials every time.  (And I could find them, too.)  These are also the easiest to prevent.

Getting Paid

  1. Everyone in the agency should be aware of the signature requirement.  The primary responsibility should lie with the first person who sees the orders whether it is the marketer or the person receiving the mail.  However, nobody should see an undated signature without bringing it to the Director’s attention.
  2. Be obnoxious about dates.  Buy some file folder labels and print, ‘Please sign and DATE your signature’ at the bottom of every order.  Use red ink.  Make it interesting and noticeable.  Add a note about dating signatures to your fax cover sheet used for orders.
  3. Because marketing staff often have more exciting things to discuss, make badges that read:  I need a date.  That will spark some lively conversations.
  4. With every ADR that is submitted to your MAC, include the description of homebound status as found in the Medicare Benefits Manual.
  5. After the patient’s initial episode, ensure that the face to face encounter is included in the summary. That leads me to;
  6. Write a summary.  If your agency is not writing summaries for each episode, begin writing them now. For ADR’s there is nothing wrong about documenting after the fact as long as the documentation is dated on the day that you wrote it.
  7. If you find an egregious error that cannot be ethically corrected, cancel the claim and send documentation along with your ADR.  This won’t affect the outcome but it is the classy thing to do.  It also shows that you do know how to recognize errors.  Please note that some errors can be corrected ethically.  Do not be too hasty in cancelling claims.
  8. If at all possible, have someone who has not been involved with the patient review the documentation you intend to submit.  It is too easy to read between the lines when you know about the patient.  The holes are not glaring to you.  If you have a branch or if there is an another agency owned by the same organization, trade off ADR’s.  If you do not have a sister agency or anyone in your organization, consider using a professional consulting service.  I can recommend a good one if you need one.
  9. Write a cover letter if there are any discrepancies in your documentation.  For instance, you may have a very weak patient who progressed to her highest level of functioning with therapy in a prior episode.  Note this so the chart does not look as though you have a patient in need of therapy but failed to provide it.  (Yes, the reviewer should be able to look at past claims but they should also know homebound status and when the face to face encounter occurs as well.)
  10. Share your ADR results with your staff.  It is so much easier to learn from the errors of others.  Too often, agencies don’t want word to get out on the street that they have received a ton of ADR’s.  Get over it.  ADR’s are being sent out at a rate that might very well save the United States Postal System from financial ruin.

We are always interested in hearing about those strange and somewhat inappropriate denials.   Please share with us if you have one that we might teach us all a little something about getting paid.  After all, it doesn’t matter how much congress reduces the home health payment if you are never paid.

And as always, we are available to help with ADR’s.  We read clinical records as though payment is coming from our own pockets (because it is!) and do our best to get you paid.  Mind you, we can only work with what we are given.  So, write those summaries and get signatures dated.

Managing Medications

I know that there are a million things that can go wrong with a patient in the home but for some reason, I am stuck on medications this week.  For one thing, we have some control over the medication error variables.  And I do see a lot of ways that nurses can prevent errors.

One of my clients had this brilliant idea of calling LSU and asking for a pharmacist to sit in on weekly case conferences.  As a result, they now have fifth year students sitting in on case conferences to review medications with the nurses.  It doesn’t cost the agency a thing and I think it will be a great experience for the pharmacists to see first hand the plethora of medications patients take in the home environment.

Another tool that I have been using is a free iPad/iPhone program from Medscape.   Without having to spell all the meds, I can enter in a patient’s med profile in a matter of a minute and check for interactions and precautions.  There are two download options available.  Because I do not have a 4G iPad, I downloaded the database and it works for me even when there is no wireless.  I regularly get notices to update the database so it apparently is kept current.

As nurses, we pretty much know everything there is to know about a drug before we swallow a pill.  We should hold ourselves to the same level of certainty when it comes to medicating patients.  In the worst case scenario, if you have no iPad, iPhone, old fashioned drug book, it is a law that the pharmacy’s phone number be placed on any prescription bottle.  Call them!

Another resource I review almost daily is emailed FDA Medwatch alerts.  You can click on the link.  My personal suggestion is to limit your alerts to drugs and medical equipment because otherwise you will be flooded with emails.  I made a separate folder for the FDA.  Last week I learned that some pills labeled as hydrocodone didn’t actually have hydrocodone in them and another batch of hydrocodone with acetaminophen had more acetaminophen than the label said.   I get anywhere from two to ten alerts each week.  I think it is good information.

While all of these resources are good, it occurs to me that the biggest problem I see when reviewing clinical records is an apparent lack of concern regarding medications.  I don’t fully understand it.  I think there are still nurses who think if a doctor prescribes a medication, he must know what he or she is doing.  That is expecting too much of physicians who have patients with multiple doctors and pharmacies.  Often it is the home health care nurse, in the home with all of the medications who has the only true picture of what the patient is taking.  When you start expecting even your best doctors to be perfect, think back to the last time you made an error judgment or took a short cut that resulted in an undesirable outcome.

I know for me that was this morning.   And I like having people around who cover my back.  Remember that the quality of nursing starts in the field.  And it is much easier to improve the quality of nursing in the field if the agency has a culture that promotes excellence.  So whether you are in the field or behind a desk, get serious about medication errors.

Your comments are welcome below as are your emails.

Cost Report Due Date May 31

We finally got our most recent ZPIC client charts out the door on Saturday. It was quite a little challenge but we are ready for the next. Hopefully, it won’t be you.

Needless to say, we haven’t had time to blog a lot. I plan on changing that in the near future because I miss you all. In my stead, is Dana Strong reminding us all about Medicare Cost Reports.

Also, if any of you have any specialized knowledge that you want to share, please forward to me. It is always good to have a draft or two on hand for those days when there isn’t even one extra spare minute.


Just a quick reminder to everyone that FYE 12-31-10 Medicare cost reports are due May 31, 2011. Failure to file an acceptable cost report timely, can result in 100% payment reduction by your Fiscal Intermediary.

An acceptable Medicare cost report filing consists of the following per CAHABA GBA:

• Diskette of the electronic cost report (ECR) file using CMS approved software
• ECR must pass all Level 1 edits
• A submitted print image (PI) file of the cost report. (Unless using free software.)
• Worksheet S with original signature of the administrator or chief financial officer
• A complete, legible hard copy of the MCR on proper forms (Free software users only).
• An exact match of encryption code, date and time for ECR and PI file creation.
• Settlement summary on the ECR matches the settlement on the signed Worksheet S.
• CMS Form 339 with original signatures of Administrator or CFO on certification page and applicable supporting documents
• Supporting documentation for worksheets A-4, A-5, A-6, and A-8 if applicable.
• Medicare bad debt listings, if applicable
• Adjusting Journal Entries
• Working Trial Balance which ties to Worksheet A
• Audited Financial Statements (if maintained)

The intermediary has 30 days from the date of receipt to determine acceptability. If the report is unacceptable, it will be returned to the provider with a letter explaining the reason for rejection. If the due date has expired, withholding of interim payments will begin. This withholding will be released as soon as an acceptable cost report is received.

Please remember it is important to both timely file your cost report and to ensure its accuracy for any future PPS rate updates.

Any questions, please contact me for any cost report filing assistance.

Dana Strong
Strong Consulting LLC
1 Steeplechase Drive
Scarborough, ME 04074
207-883-8790 (phone)
207-883-8789 (fax)
207-650-1034 (cell)

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