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Posts from the ‘Medicare Coverage’ Category

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.

Feb 19

15 Comments

Confined to the Home

Here’s the point of this entire post.  Medicare knows the definition of ‘homebound’.   Medicare states that patients don’t have to be bedridden but there must exist a normal inability to leave the home and that when the patient does leave the home it requires a taxing effort.

As it turns out, most of us and quite a few physicians also know the definition and write it verbatim on visit notes, care plans and face-to-face documents.  When Medicare documentation calls for ‘reason homebound’, they are not asking for their own definition.

So, here’s my way of avoiding those pesky denials related to homebound status and overturning the ones that do get denied.  At the time of admission or recertification document all of the reasons why the patient can’t just up and go and all contributing factors.

These are very incomplete lists but I always try to support homebound status with as many factors as are applicable to the patient.

Absolutes Supporting Reasons
Severe pain with ambulation multiple medications that can impair balance
Safety concerns due to recent hx of multiple falls. multiple meds that can impair judgment
Disoriented to person and place and must be supervised at all times urinary incontinence
Short of breath while talking, eating or repositioning in bed cumbersome assist devices
SaO2 drops to 87 with activity apprehension about leaving home
Unable to ambulate safely s/p hip replacement moderate pain after standing for extended periods
Impaired judgment secondary to psychiatric illness cannot open some doors, drive or use left arm to balance due to splint
High risk of infection due to open wound and compromised immune system. requires considerable effort communicate needs clearly due to residual aphasia and paralysis of dominant hand.

 

Note the difference between the Absolutes and Supporting reasons.  People are not considered confined to the home because of apprehension alone but it adds depth to a complete picture of a patient with severe pain when ambulating.

Patients short of breath while talking or eating who are also incontinent and rely upon an assist device to get to the restroom are at very high risk for falls.

Documenting all assessment findings that contribute to homebound status at least once an episode and then continuing to support these reasons in your visit notes may very well get you paid.

486 Summary Example:  Patient homebound due to hip replacement two weeks ago and cannot walk without another person assisting him with his walker.  He is taking narcotic pain medications which increases his risk for falls and there are steps without a bannister leading to the front door.

The truth is that we all meet Medicare’s definition of homebound status at times.  Isn’t it hard for you to leave the house in the morning?  Surely it is a taxing effort for you to make sure all the kids have their lunch and homework, find your keys, retrieve your cell phone from the litter box where the toddler put it and somehow make it to the car.  If a normal inability does not include four trips to the car and back to house to retrieve forgotten items including the baby, then crazy is the new normal.

Medicare doesn’t care about any of that. They want to know, from a clinical perspective, how the patients meet the criteria they set forth for us in the conditions of participation.  We need to paint a crystal clear picture and not just write enough to meet guidelines.  When you are finished documenting homebound status, there should be no question that the patient cannot and does not leave the home.

If there is a question, go take a second look.  If you cannot elaborate on ‘SOB with exertion’ (as I am after climbing 6 flights of stairs), your patient may very well not be homebound.

Of all the wild excuses for denials lately, this one is not so unreasonable.  We can do this without changing the law, involving physicians, and praying that the grammar police don’t get us.

Good luck.  I am very confident we can take this denial off the table.

Jan 23

4 Comments

MLN Clarification

Jennifer Barker, a dear friend and the administrator at Audubon Home Health knows me well.  She gets that I do not open emails without a compelling reason to do so and she made sure her I opened hers today.  The subject line was:  WTH?!?  If there had been even one more exclamation point, I suspect the email would have opened itself.

Her concern was with the most recent MLN guidance for the Face-to-Face document which was updated with examples on January 15, 2014.  I read it briefly and did not fully understand her concern until I went back to her email.

Before I tell you Jen’s concerns, go look at page 10 and 11 of the MLN guidance. 

Did you see it? 

Jen pointed out that apparently MLN matters doesn’t realize that home health agencies type up the plan of care.  In MLN’s defense, there is a line that states that MD ‘documents’ the face to face encounter on the plan of care but since there is no change in font or color, it appears as though the encounter documentation is part of the original information sent to the MD for signature.

WARNING:  YOU – AS A HOME HEALTH AGENCY OR HOME HEALTH AGENCY EMPLOYEE – MAY NOT CONTRIBUTE TO THE DOCUMENTATION REQUIREMENTS OF THE FACE-TO-FACE ENCOUNTER.

So, I started looking some more.  The MLN matters document mentions a couple of times about the MD dating the signature of the face to face documentation.  Did that change?  Why on page eleven is it necessary for the MD to sign twice?  I’m just curious.  The Medicare Benefit Manual, chapter 7 pertaining to home health states:

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.

There is certainly nothing at all wrong with a dated signature and by far, two signatures are better than none.  However, do not be misled into thinking that your face-to-face documentation is incorrect if your:

    1. Face-to-face encounter is documented on the plan of care which is signed and dated by the physician (in which case only one signature is required and that signature is dated)
    2. An addendum is attached to the plan of care documenting the the face-to-face encounter which is signed by the physician (a date is not incorrect but is not mandated according to the Benefit Manual).

The note on page 2 of the MLN matters information may contradict the manual although due to the sentence structure, I am not sure what the note actually means.  It reads:

Note: The homebound status of the patient and his/her need for skilled services must be written in a brief narrative, signed by the physician, titled “Home Health Face to Face Encounter”, and dated.  (Exactly what must be dated in that statement?)

Remember, these are the instructions that your referring physicians are receiving.  There is no point in contradicting them as a date will not invalidate the face-to-face documentation.  However, I do not suggest going back for a revision if a face to face encounter document does not have a dated signature.

Hey, I have an idea…..  Let’s focus on taking care of patients next week.  Any ideas of how we can help each other become better nurses?

Jan 18

8 Comments

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

E-mail: Medicare.Appeals@hhs.gov

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. 

Jan 9

6 Comments

Whoa! Slow Down! (the disease process….)

Many thanks to one of my internet friends, Guy Davis who works with the HomeSight Programs, I have received a Palmetto notice that I obviously missed earlier.  This one, unlike thousands of others, is actually important.   It tells us that skilled services can continue to be provided as long as they are required for the maintenance of the patients current condition or to slow down the progress of a disease state.  Based on the Jimmo settlement, there are now updates to the Medicare Coverage Benefits Manual for home health that read:

    …Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition.  Medicare Benefit Policy Manual, Ch. 7, 20.1.2

    …Skilled Nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided. … MBPM, Ch. 7, 40.1.1

    Maintenance Therapy – Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered physical therapy services. …  MBPM, Ch. 7, 40.2.2.E

This does not mean that you can adopt patients for life or continue to teach and re-teach the same material.  It does not extend Observation and Assessment beyond three weeks if there is no documented real potential of an exacerbation. 

It does mean that patients who respond to therapy and suffer less pain because of therapy may continue to receive it as long the therapy is of a complexity that it can only be rendered by a skilled therapist.

The case that comes to mind is one that was denied a couple of years ago.  The patient suffered from multiple skeletal deformities which compromised the space in her thoracic cavity and gut for her organs.  Without regular therapy, she would have spasms to the extent that she fell off her scooter.  Nobody else could perform the therapy which consisted of deep tissue massage among other modalities because of the skeletal deformities. 

This is an extreme case but maybe not so extreme in light of Jimmo.  Remember, you can see a patient to maintain a condition or slow the progress but ONLY when the complexities of the skill require a therapist. 

Does anyone have any patients they think they may have discharged prematurely in the past that met the Jimmo criteria?

I wonder about some wounds that simply will not heal.  If it requires the skills of a nurse to safely render care to prevent infection or expansion in wound surface area, would it now be covered?   Speaking of Guy and Homesight, what about the visually impaired patient who requires regular checks for macular degeneration to quickly identify opportunities for laser therapy and thus, prevent further deterioration? 

I do not expect any colleagues to take advantage of these changes to the coverage manual without bringing needed benefits to the patient.  I think if you take the time to read my blog, you passed up that level of sleaze a long time ago.  On the other hand, I have been heartsick at some discharges in the past where a patient was not going anywhere.  It was like they were suddenly stable at the lowest level of functioning they could reach.  They needed home health nursing or therapy but according to our guidelines, they simply did not qualify.

Many thanks to those who fought long and hard for the Jimmo settlement.  It isn’t going to open the doors for abuse of the Medicare benefit but it will make a world of difference for a small group of patients who genuinely need us.

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