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Posts from the ‘Home Health PPS’ Category

Oct 6

9 Comments

My New Hero

 

Like most superheroes, it is best to worship him from afar.  In fact, I don’t know his name and do not want to because I like a world full of possibilities.  My new hero is a physician in Florida and because he remains anonymous, every doctor in Florida could be him.  Florida is even sunnier and warmer with all those potential superheroes in white coats.

There are some heroic physicians who save lives or invent new procedures.  For the longest time, I was leery of the Whipple procedure because I was unaware that it was named after Allen Whipple.  I thought the term ‘Whipple’ referred to a technique and I didn’t want to know anything more.

Other heroic physicians travel to countries far and wide taking care of patients that have no one else.  These docs and other healthcare providers also have my undying admiration.

My new hero is a different breed, though.  I know of him by a client’s report that he documented homebound status on a Face-to-Face encounter with the following:

He is.  This is a stupid question.

Many of you may think that compared to Christian Barnard or Allen Whipple, this isn’t really such a big deal.  You could be right but I don’t think so.

In order for Drs Whipple and Barnard and the like to be of value to society and their chosen field of medicine, three things must happen.   The first is that the patient must live long enough to have the procedure done.  The surgery must be performed on a candidate well enough to undergo the procedure.   The patient must receive nothing short of excellent care after hospitalization.   Sadly this involves money.   (Average operating room time alone, without physician charges costs $147.00 per minute.)

Meanwhile, home health agencies are being denied daily because the physician does not document how the patients condition confines them to the home.  Claims are denied even when patients are recently discharged from the hospital with a serious illness or surgery to replace something like a hip or heart or whatever.

When home health care agencies don’t get paid, they are faced with choices that eventually result in providing care that is substandard or closing their doors altogether.  That means a poor outcome for the replacement parts.

We have all tried, in our own way, to gently hint to Medicare that the F2F encounter document is stupid.  NACH has even filed a law suit full of big words spanning numerous pages.  Medicare responded that they may relax the requirement in the distant future but no further word has been forthcoming.  I suspect they just wanted to minimize the importance of NAHC’s lawsuit.  I could be wrong, though.  Never let it be said that I am always right.

My hero, the unknown physician, has described in five words, why Medicare is getting so little compliance on the F2F matter.  Please note that the physician wrote two complete sentences with both verbs and nouns and I hope he gets partial credit for writing a grammatically correct narrative that doesn’t simply restate what is written in the manuals about homebound status.

Like most docs our superhero probably saves a few lives here and there and makes other people feel much better about being alive when he isn’t answering stupid questions on a stupid form verifying that he saw a patient he just discharged from the hospital.

Luckily for my diligent client, the claim had not been dropped for the patient yet.   I hope they make a photo copy of the original document before they go waste another hour of their time and the doctor’s time by once again explaining what an expensive comment that was and asking for a do-over.  If this chart is ever summoned by the payor sources, I  think I would include the original and the Do-Over.  You know, just a subtle little message – because I am all about being subtle.

Will everyone please bow their heads and give my hero  a moment of silence in honor of his insight into our daily struggles.  It is the least we can do for a physician who has contributed so much to so many.  Hopefully there are more waiting to come out of hiding.

Jul 2

9 Comments

Face-to-Face Changes?

Many thanks to Tom Calhoun of Bayou Home Care for forwarding me the CMS update regarding proposed Medicare changes to the PPS system while I was out and about yesterday afternoon.   (Be sure to click on the link and watch the video on Bayou Home Care’s page.  You will understand why I am proud to be known a swamp rat).

Like everyone, I was excited to see CMS start to back off on the unclear, ambiguous and cumbersome requirements of the Face-to-Face requirement.  The proposed changes are as follows:

  • Eliminate the narrative requirement but the certifying physician would still have to document that a Face-to-Face visit occurred and include the date of the visit.  Since nobody can agree on the definition of a ‘narrative’, this is probably a good thing.
  • Medicare proposes the consideration of records from the certifying physician or discharge facility ONLY when determining eligibility.
  • Physicians billing for certification/recertification for home health services will be denied if a patient is found to be ineligible.

The requirement that only the physician or discharge facility will mean that we can no longer turn to specialists records or pharmacy and other providers of care to support arguments of eligibility or homebound status.  I’m not too worried but be very aware of this in the future should these changes come into law.

If you are interested in what your physicians bill for home health certification, check out   Propublica’s  Treatment Tracker and find your docs.   Most do not bill often enough for certification/recertification visits to suffer appreciably from this requirement but some do.

All of this sounds really good, huh? It is – if you are an agency who has never been denied for providing good care to an eligible patient due to a poorly constructed Face-to-Face document.

Word of Caution

I tend to be overly sentimental and my first response to this update was an outpouring of warm feelings towards Medicare.  Luckily, I forgot to post this last night and have had time to reconsider my emotional response.

The proposed regulations by Medicare, should they go into effect, will not address any denials that occurred prior to the changes.  Recently, Palmetto sent a memo to y’all reminding you that no matter when a patient was admitted, the Face-to-Face documentation must be included with an ADR.

In other words, these changes offer no avenue of relief for denials that have occurred in the past.  It also allows for limited denials related to the Face-to-Face document in the future if the start of care date occurred prior to the proposed changes.

The lawsuit filed by Bill Dombi, for NACH – your association – takes the position that the regulations written to satisfy the Face-to-Face requirement were never legal.  If NAHC prevails in the lawsuit, then agencies may have recourse for prior denials if all other criteria were met.

I emailed Bill Dombi to determine if I was understanding this correctly and his response was that I appeared to be correct.  That’s about all you will ever get from a lawyer without depositions, cataloged evidence, sworn statements and DNA – the appearance of being correct.   In this case appearance does count.

So, welcome the changes.  Rest comfortably knowing that there  is a little gang in congress who are willing to relax the requirements implemented by the Grammar Police.  This is a start – not the finish to the remediation of an unwarranted attack on home care for grammatical errors.

Under no circumstances, should you become complacent.  The denials that occurred in the past were unfair and new rules taking effect at a future date will not change that. Similarly, don’t overlook the significance of the proposed regulations as it is appears that someone in Washington is listening.

Again, Thanks to Tom and to Mr. Dombi for taking time out of their days to keep me informed.

Jun 11

3 Comments

NAHC v US DHS

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

I have never been a big fan of associations and organizations.  I am not a joiner in general.  Specifically, I have been very frank about my feelings towards the National Association of Home Care and Hospice.  I believe that in the past they took on causes that benefited some agencies at the expense of others.  In many ways, it is almost impossible to be an organization representative of all agencies of all sizes in all parts of the country.

As of June 5, that changed.  William A. Dombi, attorney for the plaintiff – your association – has filed suit against the US Department of Health and Human Services.  NACH is challenging the requirements regarding documentation of the Face-to-Face encounter.  They allege that Medicare is enforcing the Face to Face encounter requirements in ways that were never intended and are not legal.  They note that these retroactive denials are made outside of the consideration of the care needed by the patient or the quality of the care rendered to the patient.

This is good stuff, y’all.

Because I was so outspoken and passionately against the position NAHC took in the past regarding other issues, I owe it to the Association (and to myself) to be as outspoken and passionate in my support of this lawsuit.

If NAHC asks anything of its members, please cooperate to the best of your ability.  If nothing else, send the board at NAHC responsible for approving the filing of the claim a note of gratitude.  This is one position that NAHC has taken that benefits all agencies, patients, and the Medicare trusts.

I can respect that.

Sep 5

3 Comments

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.

Jul 8

2 Comments

Reducing Fraud

Everyone agrees that the industry has had enough of fraud.  In fact, some industry leaders have already declared, ‘Enough is enough!’.  I wholeheartedly concur with that eloquent and emotional pronouncement of the common values of Home Health Providers.  So lets take a look at how we can reduce fraud and cut the home health budget, shall we?

  1. Ensure that nobody gains entry into the Medicare program without undergoing a criminal history background check.
  2. Test all owners and managers according to standards set forth by The Secretary to ensure that all owners and managers understand HIPAA, coverage guidelines, compliance rules, marketing guidelines, etc.
  3. Require providers to put up a 100K surety bond and demonstrate they have the capital to operate.
  4. Mandate compliance programs or if you prefer, ‘Promulgate rules requiring home health agencies to have in operation a compliance and ethics program designed to prevent and detect criminal, civil, and administrative violations’.
  5. Do not issue provider numbers in geographical areas where there is a lot of fraud or where there are a lot of providers.
  6. Put a Cap on Episodes much like IPS.  Urban agencies will be limited to less than two episodes in the aggregate and rural agencies can go up to 3.2.
  7. Penalize agencies who do not bill for LUPA’s.
  8. Have the MACs (FI’s) perform a payment review on  a random sampling of claims in all agencies to make assumptions about the agency based upon OASIS data prior to paying claims to ensure accuracy of claims.  I am available at my hourly rate to assist agencies in this process which resembles RAC audits.
  9. Place all new agencies or agencies that acquire new provider numbers to  them on a 100% percent prepayment review of claims.
  10. Get rid of the therapy thresholds.
  11. Tighten up the face to face encounter time frame so that all patients except those who have just been discharged from the hospital must be seen within 14 days of admission..
  12. Allow Nurse Practitioners to sign plans of care.

It is possible that one or two of you are sitting there wondering how I ever became so brilliant and are willing to stand up and fully support these recommendations.

It is equally possible that some of you think I am knitting with one needle or that my IQ  roughly equals room temperature this weekend.

As such you would all be wrong.  These suggestions have already been presented to Congress by The Limited Partnership for Quality Home Health Care.   Click on the link to view the eight (8) members of The Partnership.  Is anyone surprised by anyone on the list?

In case you think that Bill Borne and his friends are just trying to mess with me, I encourage you to read their petition to congress.  It describes an entire proposed Act of Congress called the SHHIPS Act.

I have never had an act of congress – even proposed – named in my honor.  I want a Planet Wackadoo Act that eliminates stupid and/or greedy people from health care.    Better yet, what about a Put Patients First Act that prohibits determining care based  upon arbitrary numbers that coincidentally benefit the Elite Eight at the expense of the group of the other approximately 6,000 home health companies in the country?

As the week goes by, I will share my thoughts on the individual recommendations.  Meanwhile, we have a voice.  If you have any strong opinion about the SHHIP  – even if you disagree with me, use your constitutionally guaranteed right to be heard by those you elect to office. 

Now, go for a long walk, get some tea and clear your head.  We have work to do.

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