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Posts from the ‘OASIS’ Category

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.

Data Submission


Have you submitted your OASIS data?  All of it?  Have you looked at your validation reports in great detail to ensure that there was not one fatal error that may have been overlooked?

What about your HHCAHPS data?  Have you been diligent about submitting it?  If your agency had less than 60 patients from March 31 through April 1, have you submitted an exemption request on the HHCAHPS website?

If you are not 100 percent sure about these answers, it might be a really good time to find out and ensure that  you have met your data submission requirements.  You will be penalized if your OASIS and/or HHCAHPS data isn’t submitted.

The penalty sounds modest enough – 2 percent.  But unless you are really good at doing business or really bad at taking care of patients, that 2 percent could be anywhere from 20 to 50 percent of your margin.  If you are really good at taking care of patients and mediocre in the business area, this modest 2% could devastate you.

The Medicare Guidance, which can be found here, reads:

In calendar year 2007 and each subsequent year, if a home health agency does not submit required quality data, their payment rates for the year are reduced by 2 percentage points.

Notice the reference to the year 2007?  The actual reg has been in effect even longer than that and only a couple of agencies here and there were penalized.  The Office of the Inspector General took notice of that earlier in the year and penalties are on the way.  The  Medicare Administrative Contractors (MAC’s – formerly FI’s also known as Palmetto, Pinnacle, etc.) have received these instructions straight from CMS:

Each fall, Medicare contractors with home health workloads will receive a technical direction letter (TDL) which provides a list of HHAs that have not submitted the required OASIS and/or HHCAHPS data during the established timeframes. These Medicare contractors shall review their paid claims history for claims which have:

  • a provider on the (naughty) list
  • Dates of service from July of the previous year
  • Beneficiaries over 18

Here’s the part that is really good:

If the contractor finds any such claims, the contractor shall notify the HHAs that they have been identified as not being in compliance with the requirement of submitting quality data and are scheduled to have Medicare payments to their agency reduced by 2%.

I have yet to see where a threshold for compliance has been set.  It does not say if the majority of data was submitted or if 90 percent of the data was received.

It also doesn’t say how they are going to identify the providers.  Will they look for gaps longer than 3o days between submissions?

My experience is not reassuring.  Agencies have received deficiency notices for late submissions but there have a number of times over the past few years when no data was submitted.  Nothing has been received when no data was submitted.

In one agency, a young lady had indeed submitted the data and placed the validation reports in a binder just as she was told.  Her instructions should have included reading the reports.  Every single assessment had been rejected for a period of six months.

Several times in several different agencies, the person responsible for data submission left employment.  When they did, nobody picked up the relatively insignificant task of transmitting data.

If I were an administrator or a Director, you can prevent disaster by:

  • Requiring OASIS data to be submitted every two weeks.  It is not unheard of that uploading data is difficult and time consuming
  • Require written confirmation that the task was done.
  • If you use outlook, put a recurring reminder with an email that goes out two days before data is to be uploaded.  That way, if you forget about all this a year from now and the person uploading the data leaves, you will get a bounced email
  • Actually look at validation reports and ensure they are being addressed.
  • A system of verifying with your HHCAHPS vendor that submission of data has occurred according to your contract.

If you are a field nurse or someone else who doesn’t deal with OASIS transmission, don’t hesitate to bring a copy of this to the people who do to remind them of the importance of it.  If they are offended, walk it off as my son’s coaches used to say.  I can pretty much guarantee that you will not get a raise next year if your agency takes a 2 percent hit.

Basic OASIS Competency


Do you dare? Here is a basic OASIS competency test.  It could be that you know more than you think you do or it could be that you might want to spend some quality time with chapter 3.  You never know until you try.  Click the OASIS icon below to take the test.

Short and Sweet Documentation Quiz


So, I spend a lot of time trying to teach nurses how to document.  I really don’t enjoy as much success as I would like but it isn’t for lack of trying.

After reading charts from agencies chosen for ZPIC audits, I decided it would be easier to teach you how NOT to document.  Please understand that if you document like the examples in our little documentation quiz that I cannot help you.  The best lawyer in the world probably cant even help you except to maybe reduce your prison term.

Take the quiz.  I can’t wait to see your answers.

More on Medicare Fraud and Abuse


Apparently, HHS Secretary Kathleen Sebelius ad Eric Holder, the US Attorney General had a ‘summit’ regarding Medicare Fraud and Abuse.  You can read the whole report here.

At the summit, Secretary Sebelius announced that starting July 1, HHS will begin using innovative predictive modeling technology to identify fraudulent Medicare claims on a nationwide basis, and stop claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made.

I think this is a good idea.  There are patterns of abuse that repeat themselves in almost every fraudulent agency and it is easy to write programs that identify them.   In one of my ZPIC audits that I am working, there is a clear and distinct pattern of low utilization combined with very long lengths of stay.  This is not to say that all patients had old start of care dates.  Many of the patients have been admitted and discharged several times over. The numbers you review regarding length of stay based on individual admissions may be lower than what the feds calculate based on the entire claims history of the patient.

Another pattern that shows up repeatedly is high therapy use.  I have two excellent clients that have inordinately high therapy use but I don’t worry about them.  Many of the patients are total knee replacements or other ortho surgery and after six to nine visits, the patients are discharged.  But if all of your therapy patients are being seen for ‘gait instability’ related to chronic illnesses and all of them receive 14 or more therapy visits, expect to find yourself on the ‘naughty list’.

Overuse of any one diagnosis code alerts the feds to potential fraud.  Not everyone with impaired vision has a diagnosis that can be supported with physician documentation.  And most who do will have other claims in the Medicare system that supports the diagnosis such as ophthalmologist claims and pharmacy claims for eye medications.  The feds access to information is unmatched.  If they use it properly, no one who is even an inch over the line will be spared.

What I find particularly sad is that when I look at agencies’ clinical records, I see some practices that are common, ineffective and are certain to place the agency on a watch list somewhere.  For instance, a nurse will have been taught, and in very good faith believes that if a patient has diabetes, it should always be primary because it pays more.  And then she goes to work for one of my clients and it may take a while before the diagnosis problem is discovered.  And yet, these same agencies are continually leaving money on the table by not assessing a patient accurately.  They routinely increase payment inappropriately by a few dollars while ignoring the hundreds of dollars per day they leave on the table.

Before I take on any client, I look at the CMS reported outcomes.  In particular, I look at the hospitalization rate calculated by CMS. There may be various reasons why different agencies send their patients to the hospital but when it comes to extraordinarily high hospitalization rates (over fifty percent), there is only one reason.  The agency does not discharge patients to the community.  In other words, most of the patients who are discharged from the agency are discharged because they are in the hospital over the end of the episode and the discharge is because the agency has not been able to follow OASIS requirements resulting in a discharge and readmit.  If you think the Feds don’t know this, consider that I know it and I have a fraction of one percent of the data the feds have available to them.

So, look at your numbers.  Look for patterns.  If you are concerned that the new data mining implemented in July may pick up on some unusual patterns in your agency call me.  I can be reached at 225.253.4876 or you can always email me.  I will find your patterns, deconstruct them and help you reconstruct your care so that you make as much money as you ethically can without creating patterns that even remotely resemble anything less than one hundred percent compliant with Medicare payment guidelines.

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