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Posts from the ‘Medicare Fraud and Abuse’ Category

Turning Point


My understanding of the events that shook my world last night is that they began before Hurricanes Katrina and Rita.   Although I am not certain of this, it seems that an investigation into Abide Home Health began prior to the storms but the evidence was washed out to sea.   I can’t say if that’s true or not but it adds a level of interest to the story knowing that the agency had a new chance to do things right and chose not to do so.

The case involved over 20 defendants, illicit sex, a dash of racism, the mother of a prominent football player (The Honey Badger), a large oil company and two Zulu Queens.  For those of you not from the South, Zulu is a Mardi Gras parade and they were Carnival Royalty. This is a big deal in New Orleans social circles.

To be sure, this case was juicy.

Imagine for a minute that you are one Lisa Crinel involved in a romantic relationship with your lawyer when a search warrant is executed relating to a fraud investigation involving your business.  Imagine if it was signed by a federal judge who was married to your lawyer.  Now imagine that you are the lawyer when Lisa Crinel files a lawsuit alleging that the lawyer ‘“never informed Ms. Crinel that it was a conflict of interest for him to represent her and her company while carrying on an extramarital affair with her….”   Yes, indeed.  How else could she have known?  I’m betting the judge was unaware of the affair when she signed the search warrant because it didn’t include a cavity search.

For some people, Medicare fraud isn’t enough.  The original press release from the US attorney’s office in Eastern Louisiana alleges that Lisa Crinel created false documentation to support claims for two employees and her daughter so that they could collect money from the funds provided by BP to compensate real victims of the Deepwater Horizon oil spill.  Classy.

Moving right along, Ms. Crinel had already lost 1M to the feds who seized her property even before she was indicted.  This was interpreted by Lisa Crinel as being racially motivated because they did not seize the property of another Medicare defendant accused of the same crime.    I believe there is a possibility that something, other than race motivated that decision.  Could there have been a previous overpayment?  How strong were her ties to the community?  I have to admit, a beach in a country without extradition might have appealed to me if I were in that position.   I sincerely hope that federal investigators did not simply seize her property and bank accounts with no good reason prior to the indictment because in spite of mountains of evidence, Ms. Crinel was innocent until proven guilty.

The Turning Point

In October of 2015, Lisa Crinel woke up with a newly calibrated moral compass.  In exchange for a lighter sentence of no more than 8 years and an agreement from the Assistant US Attorney that all felony charges be dropped against her daughter who served as CEO, she pleaded guilty.  She explained her decision, ‘because I am in fact guilty, and because I did not want to put the government through the unnecessary expense and trouble of proving this in court. I also pled guilty because I understand that accepting responsibility for the wrongs that I have done is the first step toward correcting them.”

Of course, she also agreed to provide the prosecutors with any truthful cooperation in any way she could.  According to Ms. Crinel, this was a genuine personal turning point for her, not just a legal one.  Yes.  That’s what she said.

The Sad Part

Last night, four doctors were convicted of multiple counts of Medicare fraud.  The longest possible sentence I saw was 170 years although the sentencing date has not been set. yet.  Are they guilty?  I think they are.  I still don’t know all of the details but the Feds don’t lose.   They knew this case was their’s for the winning when they took it on.  They turn away far more cases than they accept and the do not indict until they are certain they have a case.

Of the four, I know one mainly through his office staff.  I know that he was with his grandson who was receiving chemo when his office was raided.  I do not believe this was an accident because I’ve heard too many other stories about the feds arriving when the targets of their investigation were least available.  I have followed behind this doctor and another and read their clinic and hospital documentation for years.  The truth is that they are razor sharp physicians who are responsive to their patients and the nurses who call them for orders.

They are basically good men.

So, what happened? One doc received $3,500.00 a month from the agency – $1,000.00 more than would be allowed by law assuming he worked for the paycheck.  None of the doctors were poor and they all made more money than most people reading this blog.

My anger towards the owner of the agency is what I hang on to while these questions still linger.  Lisa Crinel owned Abide Home Health.  Her daughter was the CEO.  They wrote and signed checks that went to physicians.  They paid a physician’s wife an inflated salary so that her husband would refer patients.

Did the docs approach her asking for a Medical Director position?  I bet they were approached by Lisa Crinel.  And what they saw was a successful business woman in New Orleans – an economic nightmare since the storms in 2006.  They saw someone who had overcome the odds and lived well.  They signed orders because she or her agents asked.  Did they trust that the orders were legitimate?

Did they get a little greedy rationalizing that the dollar amount of money may be technically fraud but they deserved it?

These physicians could not have realized they were risking what may amount to life sentences for the relatively small amount of money they received.  But that doesn’t matter.  The standard isn’t what you know but rather what a reasonable person in the same position has the responsibility to know.

Lisa Crinel had the jewels and cash paid for by the proceeds of the fraud.  She was a New Orleans socialite; queen of Zulu.  She was a leader of the community and she lead dozens of her followers to the jailhouse.  While the physicians earned most of their money providing care to patients, she stole all her money by committing fraud.  And when she ran out of lawyers available for affairs and the BP scheme fell flat and nobody would believe that her African American heritage was the reason the feds were picking on her, she turned on the very people she recruited to participate in her fraud scheme.  I’m not sure I have any respect for her.

And New Orleans has lost two great physicians and two more that may or may not be great.  I’m not disagreeing with the verdict but I still find it sad.   The jury found them guilty and I trust the jury.  But they are guilty of fraud; not of being scumbags who systematically scheme to steal as much as they can from the government.   Sometimes good people break the law.

PEPPER Reports


What if I could tell you how likely you are to find your agency under intense scrutiny by Medicare?  Would you want to know?  What if I could tell you what Medicare expects you to do to address any risk areas?  Would you do it?

Chances are the answer is a resounding, ‘No!’

You can have all this information within 15 minutes.  All you need is your provider number and a patient ID number for a claim that has been paid prior to July 17, 2016.  Both of these numbers are available on any 485.

Using these two numbers, any Medicare certified home health care agency can access the PEPPER portal.  There you will find your agency specific reports that show where an agency falls compared to other agencies in areas that Medicare has identified as those being closely associated with Medicare fraud and abuse.  Of all certified home health agencies, only 20 percent nationwide have bothered to look at their data.

One nurse asked me if maybe it was better not to download reports.  Her rationale was that if Medicare would come down harder if they believed the agency was aware of any high risk areas as opposed to being unaware.  To be clear, Medicare is not going to cut you a break if you didn’t know that your agency was meeting the threshold for any of the target groups reported.

Here’s what the PEPPER reports show:

Average Case Mix

Agencies with an average rate of 1.6 or higher may find themselves looked at for possible up-coding.

Average Number of Episodes    

Nationwide, agencies in the 80th percentile provide an average of 2.78 episodes.  Medicare believes there is a high chance of improper payments if you meet or exceed an average of 2.78 episodes per patient.

5 or 6 Visits                                       

In order to get paid the full amount for an episode, an agency must provide at least five visits.  Any nursing care over and above five visits adds to the cost of the episode but not to the payment.  If your agency has more than 7.2 percent of their episodes with five or six visits, Medicare believes there is a chance that you are maximizing income without regard to patient care.

Non-Lupa Payments                      

Medicare expects that agencies will have LUPA payments.  When the number of LUPA payments is very low, Medicare suspects that an agency is avoiding LUPA costs by providing unnecessary visits to qualify for full payment.

High Therapy                                    

Although some patients require 20 or more therapy visits per episode, the assumption is that agencies in which 2.9 percent or more of patients required 20 or more visits may be adding unnecessary visits to capitalize on the enhanced payment associated with high therapy.

Outliers                                              

The target for outliers is 7.6 of total payment.  Note that this is less than 7.6 of total episodes.   Anything over 10 percent will be adjusted quarterly.

These indicators of possible improper payments are only data.  It is possible to hit the target in one more areas without doing anything improper.  However, a prudent agency will be well aware of where they fall and document accordingly.  Should questions arise, the agency should be able to provide an explanation as to the aberrancy.  If you cannot arrive at a suitable answer, take a long and hard look at your charts.

The PEPPER reports that have been shared with us do not approach any level of concern.  (Fraudulent agencies often eschew our services which focus on compliance.)  My guess is that PEPPER Reports are effective at identifying improper payments.  Agencies that routinely provide three episodes per patient and all the episodes have exactly 6 visits may not be assessing the patient and meeting their individual needs.   If you are employed by an agency that has hit multiple targets and seems disinterested in addressing them, you may want to reconsider your current employment status.

If you decide to download your PEPPER reports, please let us know.  If you feel like sharing them, we’d love to see them and promise to keep them confidential.

End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

Read more

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.

Physical Therapy Goals


The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

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