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Posts from the ‘Home Health Physical Therapy’ Category

A Memorable Comment

Two years ago, I posted about Beverly Cooper who was convicted of multiple counts of fraud and was facing up to a ten-year sentence in Federal Prison.  See Press Release.   She admitted to signing visit notes when unlicensed personnel made the visits giving the impression that she made the visits; among other things – lots of other things.  Signing off on a visit that was made by someone without a license could have easily proved deadly to a patient.  Maybe Ms. Cooper is lucky that she didn’t kill someone.

Today, I received a message from someone, apparently a friend of Ms. Cooper’s pointing out that nowhere in the indictment (or my blog post) was Ms. Cooper’s 15-hour work days or dying relative noted.  The writer asked if I knew how wonderful Beverly Cooper was and pointed out that everybody makes mistakes.

Frankly, it would not surprise me if Ms. Cooper was a good hearted, likable woman.  Unlike less sophisticated crime, fraud on this scale is usually committed by people who are genuinely likable.

The writer of the message mentioned other people involved in the indictment.  She wanted to know why I didn’t mention them as well.  Frankly, they were not included in the press release.  Furthermore, Ms. Cooper was a Registered Nurse.   This blog is all about nursing and nurses and those who occupy our worlds.  That’s why Ms. Cooper made the blog post list.

I don’t know the person who wrote me the email and I never have met Ms. Cooper before.  I was nowhere near Detroit where all of this took place.  I cannot begin to speculate on what might have happened.  But, I can make reasonable assumptions based upon the criminal cases I have worked with and some former clients.

  1. Cooper was likely tired and emotionally fragile based upon what the writer said. Masterminds of fraud are incredibly smooth at exploiting the weaknesses of others.  She likely was not the mastermind.
  2. My bet is that Ms. Cooper was paid far more than an RN in a similar position. Should someone offer you twice as much as you are making now, be aware.  You are not worth that much.
  3. Cooper may have convinced herself or have been convinced that ‘everyone does it’. Wrongo.
  4. There may be somebody in the mix who could be legitimately diagnosed as a sociopath. Being without a conscience is mission critical to projecting the confidence required to persuade accomplices to achieve your purposes.
  5. I would bet the farm that at some point long before her arrest, Cooper figured out that she was committing fraud and had to make a decision. It could have been loyalty to her employer, a need for money, fear of extortion or just greed that convinced her to stay.  Sometimes, folks are too overwhelmed to think about a major life change.
  6. If this case was even remotely similar to other cases, the agency was investigated for years prior to an arrest. Beverly Cooper and her co-conspirators may have become complacent since there was so much time between the investigation and the arrest.

Let me reiterate that I do not know anything about these people.  They are not the usual fraudsters in Louisiana where we have enough home grown fraud that I don’t have to go looking in places like Detroit.  I have met many others who have faced a similar circumstance; enough to make assumptions.  I have enjoyed their company and worked hard for them and their lawyers and I took their money for my services.  But, when a clear pattern of fraud exists, there is nothing that I can do.  Criminal attorneys are brought to their knees trying to find a defense for their clients when there is none.   These are not thuggish criminals.  They are well dressed, well spoken professionals who say and do all the right things.

Your task if you are reading this is to know what a compliant agency looks like so you can find one to work with or create one to attract the kind of talent that you need to bring your agency to the next level.

The compliant agency:

  • Makes a lot of mistakes – it may seem like even more because they talk about mistakes, bring them out in the open and find ways to avoid repeat mistakes.
  • Has a lot of information scattered around the office about a code of conduct, employee hotlines and compliance committees.
  • Welcomes questions as a door for teaching.
  • Makes sure that employees have an anonymous way to report fraud.
  • Takes reports of fraud offered in good faith seriously.
  • Provides far more education in fraud than anyone wants.
  • Looks at processes and doesn’t blame employees for mistakes that involve multiple people and departments. There’s plenty of time to blame others if it happens again.  Fix it and move on.

Mistakes are costly to be sure but not nearly so much as hiding mistakes.  If you inadvertently make a mistake that affects billing and are fired after reporting it, smile on your way out of the door.  You don’t want to be there.  The agency has just sent a message to everyone else that they have a zero tolerance policy for mistakes and future mistakes will be hidden away.

Ms. Cooper may have been caught up in a storm she could not escape.  She may have discounted her actions as inconsequential or have been convinced she would never be caught.  She has lost her family, her marriage and her job according to the person who emailed me today.  She is completely without dignity.  On top of all of that, she is facing jail time.

I can’t help but feel compassion for her but more importantly, I am bound and determined to give all of you who take the time out of your day to read my blog the information you need to avoid a similar fate.  Unemployment is not half as bad as jail.

The Improvement Standard

Have you ever been told that no matter how sick your patient is, the Medicare Home Health Benefit does not cover chronic care?  If you are my client, you have and I certainly didn’t make it up.

As it turns out, CMS has identified the need to offer a little clarification on that requirement.  Attorneys from the Center for Medicare Advocacy, Vermont Legal Aid and the Centers for Medicare & Medicaid Services (CMS) have agreed to settle the “Improvement Standard” case, Jimmo v. Sebelius.

In a Nutshell

Skilled Nursing and Therapy services may be provided to a patient to maintain the patient’s present condition or prevent further deterioration if:

The skilled services are of sufficient complexity to require the skills of a nurse or therapist

The individualized assessment does not indicate that the services can be performed safely by an unskilled person

Effective Date

The effective date of this ‘change’ January 18, 2011 which is the date the lawsuit was filed.

Because the practice of denying beneficiaries who would benefit from skilled services to maintain their current condition or prevent further deterioration has never been legal, this isn’t an actual change in coverage.  It was merely a little misunderstanding and as noted, clarity from CMS is on the way along with an Educational Campaign for providers, contractors and adjudicators.

If you have been denied for claims related to a patient’s failure to show improvement since January 2011, appeal them.  Fill out a reconsideration form and attach the text of the settlement agreement.


In order to qualify for maintenance skilled services, the document emphasizes repeatedly the need for an ‘individualized’ assessment to reflect the needs.  Be careful in offering long term services on a routine basis but never discharge anyone who requires continuing skilled care.

This requirement will not be met by offering long term packaged skills provided as a result of a generic assessment.  You will be denied if you routinely offer ongoing range of motion services to all stroke patients.  You may be covered if a stroke patient has an orthopedic defect that would render range of motion to be a high risk endeavor for an unskilled person.

More Information

Visit the Center for Medicare Advocacy for more information.  And leave a comment about how you think the Improvement Settlement will affect your agency.

Help with Writing Goals

Attention all therapists and nurses! If you are one of those clinicians who has difficulty writing goals, refer to this video. Please share in the comments box any goals inspired by these marvelous nursing home residents.

Therapy Management

In reviewing charts lately, there seems to be a severe lack of therapy management in home health agencies that depend upon contracted therapy. It seems that in some parts of the country, therapists are in such high demand that we allow them to do as they please as long as they will see our patients. We choose between the lesser of two evils – having a rogue therapist or two or not providing therapy to our patients. This can result in poor care to the patient but most often it results in financial disasters. It doesn’t matter how much you are paid for an episode, if you spend more than you make. These are some of the problems I see regularly throughout agencies.

Referrals: An agency makes a referral to a therapist and when it is convenient, the therapist sees the patient. If therapy isn’t managed, the agency may not know that a therapist didn’t admit the patient until five days after referral. This results in poorly crafted OASIS assessments, impossible resource management and overall sloppy care. A surveyor would deem this practice as poor coordination of care and in some states, a serious hit on survey for admissions processes.

Subsequent Orders: I have never reviewed charts in an agency where all therapy orders were on the chart. In agencies that have solid therapy management plans, this happens less frequently. In agencies that take a haphazard approach to therapy management they have given the surveyors an easy tag.

Extension Orders: This happens when the agency and the therapy provider agree on a plan of care and then the therapist requests additional visits directly from the physician. One therapist I reviewed at an agency consistently did 19 visits because they knew CMS looked really hard at 20. (I don’t make this stuff up.) All home health services must be rendered under the guidance and supervision of the home health agency. I would think twice about paying for additional visits if they were requested outside of the processes of the agency.

Frequency Errors: Missed visit slips are often turned in weekly with therapy documentation. Most times the agency doesn’t even know the visits were missed prior to receiving the paperwork. If the missed visit occurred on the prior week, no agency intervention such as scheduling an alternative therapist can be made. When this results in five or thirteen visits for patients who truly needed seven or 14 visits, it makes me want to cry. Chances are my entire consulting bill could have been paid out of the loss incurred by the agency for sloppy therapy management.

Our biggest problem is that many agencies are okay with this sloppy case management because the alternative is not having a therapist. They will continue to be okay with it until a state agency places them on a termination track for repeated offenses. And no, they don’t often clear therapy related deficiencies on a desk review.

In order to manage therapy, agencies should have in place processes that include:

  • Communication with the therapist the very same day as the referral was sent
  • Inclusion of therapists in case conference even if it is only a phone call prior to the therapist by the primary nurse or case manager.
  • A system for tracking orders
  • A system for tracking visits

Additionally, agencies need to remember that all arrangements by third party providers conform to a written agreement that contains at least the following criteria as outlined by CMS:

……when a provider provides outpatient services under an arrangement with others, such services must be furnished in accordance with the terms of a written contract, which provides for retention by the provider of responsibility for and control and supervision of such services. The terms of the contract should include at least the following:

• Provide that the therapy services are to be furnished in accordance with the plan of care established according to Medicare policies for therapy plans of care in section 220.1.2 of this chapter;

• Specify the geographical areas in which the services are to be furnished;

• Provide that contracted personnel and services meet the same requirements as those which would be applicable if the personnel and services were furnished directly by the provider;

• Provide that the therapist will participate in conferences required to coordinate the care of an individual patient;

• Provide for the preparation of treatment records, with progress notes and observations, and for the prompt incorporation of such into the clinical records of the clinic;

• Specify the financial arrangements. The contracting organization or individual may not bill the patient or the health insurance program; and

• Specify the period of time the contract is to be in effect and the manner of termination or renewal.

If a therapy provider after signing such an agreement violates these terms and conditions, both the agency and the therapist may be held accountable. CMS really doesn’t care if there is an abundance or a shortage of therapists in your area!

As always, I am interested in your comments. If anyone has an effective way to manage therapy, please share it with your colleagues. You can email it to me directly to include as a blog post or paste it in the comments box below.

Job Opportunity

So you think you want a new job? Check out the CMS Recruitment Video.

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