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Denial Shock

It’s a patently bad idea to share my frustration regarding people who can make or break my career on the internet but after this weekend of working denials, I’ll take my chances.

The first denial I dealt with was the result of a ZPIC audit.  Somebody from AdvanceMed called a patient on the telephone and asked him if he drove. He assured her that he did.  The telephone interviewer, having heard what she wanted without assessing the patient, denied close to 30k in claims.

I actually visited the patient.  I also read his plan of care and medication list and couldn’t help but notice that he was on three or four pain meds that would make it very difficult, indeed, for him to get a driver’s license, but you never know.  The drive to his house included a 15 minute stretch on a country highway, another two miles down a gravel road and then the dirt road.   The trailer itself sat on over  an acre.  He had to climb five stairs to get inside and his scooter which was referenced in the denial was under the carport rusting.  It seems that it is fairly cumbersome to operate a scooter in a mobile home where three adults and three children live. 

But, what sold me on the homebound status, other than his five back surgeries, his lack of a vehicle or a license, his extensive medication list and the challenging physical environment in which he lived was the diagnosis of schizophrenia.  As early as that morning he reported having a conversation with his sister who died tragically two years ago.  He said he usually took Zyprexa and Seroquel but he didn’t that day because he had gone to the doctor to talk about back surgery.

The next denial was for $3,500.00.  It involved a claim with 7 skilled nurse visits, 9 therapy visits and a few home health aide visits.  The reviewer at Advance Med noted that there was no order for the visit to discharge the patient from therapy services.  I went back through the original scanned copy sent to the Zone and found the order.  So what?  Everyone makes mistakes and it was difficult to find.

The claim was not downcoded, you understand, but completely denied.  In full.  

My client appealed to Palmetto who upheld the original denial.  My job this weekend was to explain how the Home Health Prospective payment system worked to entities contracted with our government to monitor the integrity of Medicare payments.  That annoyed me.  I get paid by the hour so maybe I over reacted but I assure you that there are far more useful things I could be doing for clients. 

Lack of therapy orders for another client was the target of yet anther inane denial for a different client.  The client appealed AdvanceMed’s decision to Palmetto who reviewed the two signed orders (the 485 and the physician signed therapy eval and care plan) and agreed that AdvanceMed overlooked both orders.  However, the decision was noted to be ‘unfavorable’ (I love that word) because there was no distinction between short term and long term goals on the plan of care.

They were right.  What can I say?  Who really wants to hear that the entire course of therapy lasted only three weeks?

The most uncomfortable denial I worked this weekend was a claim that was part of a ZPIC request that my company prepared for a client.  They were paper charts pulled from old storage and our job was to put them order, verify signatures and notes, identify any outstanding vulnerabilities, scan 35,000 pages of documents and get them to the Zone on time.  I know you won’t believe this but we, uh, sort of…, well….. we made a mistake.

The claim I was reviewing had orders in it from 2010; a full year after the 2009 denied claim.  I missed it.  AdvanceMed missed it.  Palmetto missed it.  And now its back to me.  I found myself in the awkward position of pointing out that we sent in documentation that implied orders were written in March of one year that were actually written 12 months later.  Not only did Haydel Consulting totally miss the ball on this one but so did AdvanceMed and Palmetto, GBA.  I would like to take this moment to point out that unlike AdvanceMed, I do not have a 105M contract with my client. 

What can you learn from this? 

  1. At least once episode, fully explain the patient’s homebound status.  Being confined to the home due to pain and the need for help to leave the house will do on visit notes but once an episode, put it all together in context in case clinical record is requested for a payment review.
  2. If any claim is requested contains therapy, go buy a red Sharpie and draw a circle around the orders.  Make sure each page of the chart is numbered at the bottom.   Reference the therapy orders by page number in your cover letter.
  3. Include that the patient will win the Nobel Peace Prize prior to his or her death on all therapy care plans.  That way you can google the winners each year and monitor progress towards goals.
  4. The regulations state that all orders must be dated.  Apparently, it doesn’t matter what date you put on the orders as long as they are dated. 
  5. Haydel Consulting Services is not perfect or known for exploiting our warm and friendly relationships with Medicare contractors because we don’t have any.  Hire us anyway because we get results.  Somehow. 

Should I send an invoice to AdvanceMed and Palmetto or let my clients pass on my bill to them?  Maybe CMS could pick up the tab for educating their contractors.

I can’t wait to see what comes up next.  You’ll be the first to know if I am not in jail fighting accusations of healthcare fraud because I sent in orders that were a year late. 

Please keep me posted of any creative new denials you receive.

That Horrible Thing on Everyone’s Mind

I have been consciously avoiding the news this weekend.  I understand and am deeply saddened by the events in Connecticut like everyone else.  Sadly, there is nothing that I can do.  One more card from a stranger isn’t going to ease the burden of a small town that experienced 28 senseless and violent deaths in one day.  The pain is unimaginable and the fact that we can’t do anything about it frustrates us.

The truth is, when we focus so intently on a single thing, everything else in our lives is pushed to the shadows.  The Sandy Hook shootings are very important.  Make no mistake.  There are lessons to be learned and studies will take place and hopefully policies will be changed.  But not tonight and I am pretty sure the real lessons will not come from people on the news channels shouting over each other about gun control, access to psychiatric services, etc.

If you are reading this, you are likely a healthcare worker or work closely with health care workers.  As such, we are in a unique position to take the information we already have and put it to use in very important ways. As a professional, you can even make it a point to learn more about mental health issues.

We talk about healthcare politics a lot.  Gun control seems to be a very popular topic.  We talk about access to mental health care.  But what I have noticed in my work lately, is that we ignore mental health.

I see Zyprexa in a med list with no psychiatric diagnosis.  I see patients assessed as having no signs and symptoms of depression in the past 14 days even though they have just been released from the hospital status post open heart surgery.  If I am reading charts in areas I frequent, I will notice that a young person is living in an assisted living facility and ask why?

Sometimes I see reference to ‘drug seeking’ behavior as though the patient isn’t behaving properly.  I see enough written skillfully to read between the lines when a patient’s medications are being stolen by relatives.

These issues are not grounds for denials and I cannot recall any state deficiencies related to lack of a diagnosis related to Zyprexa.  I would certainly see a denial if a patient with high blood pressures went an entire episode without them being addressed.

So, it isn’t just ‘us’.  We have a culture that overlooks mental illness as being unimportant.  There is no lab test for it.  Patients with mental illness are often on Medicaid and we all know how undesirable a boatload of Medicaid patients are.  The interventions for psychiatric conditions are vague and the language used to describe psychiatric symptoms is strange to us.

Our patients are hardly likely to go on a shooting spree.  That is not the point.  My point is that if we, as health care workers, do not recognize, acknowledge and do our very best to treat mental illness, we are failing the patient.  That is true even if you are not a psychiatric nurse.  Patients admitted for any reason should have their primary diagnosis plus all diagnoses that affect their ability to participate in or respond to their plan of care addressed.

I’ve started you out by uploading some ideas taken from the internet on rational behavioral therapy that you can discuss with your patients who are depressed.  It sounds much more complicated than it is.  Don’t get me wrong – I love a good antidepressant as much as the next person but it is not enough to simply ignore depression while you wait for the meds to kick in.

As long as we continue to pretend psychiatric illness does not exist, we can hardly complain when others do the same.

You with me on this one?


I have friends who can do just about anything.  Fans of Pinterest, Instructables, and the DIY Network channel can build a boat from water bottles, decorate like Martha Stewart and change out a faulty transmission on their lunch break.  There are Do it Yourself legal forms in case you want to write your own will and computer programs that serve as your personal accountant.  DIY healthcare includes sophisticated diagnostic testing and when you think about it, aren’t fajitas merely a DIY Burrito kit?

Following suit, is the Brand New Amazing Do It Yourself ZPIC from our friends at AdvanceMed.

Here’s how it works:

  1. You are chosen based upon statistical aberrations in your claims pattern.  One agency may be chosen because a certain percentage of patients have been on service for a very long time.  Another may be chosen because of the amount of therapy provided.
  2. A letter arrives in the mail.  It will have the name of a benign sounding company like AdvanceMed or Safeguard Services.  If you live in the Northeast, your Zone Contractor is listed as ‘Under Protest’ which I believe is a reference to the contractual agreement with CMS but wouldn’t that be a cool name for a Zone Contractor?  In spite of outward appearances, this is not junk mail.
  3. It references a list of patients and tells you to perform a review on those patients and assess for eligibility.  One agency had a list attached.  I believe they are the only one.  If you have seen a list, please advise STAT.  You may do so in a confidential email. You may have stumbled upon a rare document worthy of placement in the library of congress under glass.
  4. After completing assessment referenced in step 3, you are asked to send a report to AdvanceMed advising them of your findings along with a check to cover any overpayments.
  5. The letter goes on to strongly suggest that the agency stop everything and complete a 100% review of all records in their agency to assess for any compliance issues.

I regret that I was somewhat high the first time somebody actually read me one of these letters aloud.  The recipient of said letter did not find it as amusing as I did.  I promise to never take a work relating

After the meds wore off, it did occur to me that these letters could be very disturbing to an agency.  What exactly do they mean by a strong suggestion?  I strongly suggest that everyone exercises daily but many people do not and there is no penalty (other than heart attacks, strokes, obesity and diabetes).  I suspect that the Zone’s suggestion carries more weight than mine.  But, I have no way of knowing.

What really amazes me is the clever new reasons given for denials:

  1. No OASIS data found in the state repository
  2. ICD-9 Coding (Not new but the the focus is no longer on Diabetes and hypertension; it is now low vision)
  3. My favorite – the one I wholeheartedly concur with reads as follows:

Quality of care is questionable as the nursing visits were not increased to follow up on elevated blood pressure.

Another denial read the same thing substituting new meds for blood pressure.

If you are the recipient of a similar letter, please feel to call upon us for help.  If your agency does have the time and resources to drop everything and do a complete review of all clinical records, please email us anyway.  I am particularly interested in knowing if you received a list and what statistical aberration you reflect.

If you are not a recipient yet, it may be a good time to review all your validation reports since Jan. 1, 2010 and ensure that OASIS was submitted for all claims prior to billing.  You may also want to rethink your approach to care planning and get out of the 1W9 mode.  For information about coding low vision, check out The Coders blog.

I fully anticipate that the feds will be mailing letters to suspected drug lords asking them to perform a complete search of their home and report back with an inventory so that a sentence can be arranged.  I draw the line at DIY dentistry, though.


Company May be on the way….

Lately, some agencies in Mississippi and Louisiana have been entertaining Zone Contractors.  They arrive at an agency and ask for 30 complete claims to be produced that day.  ZPIC activity is not public knowledge so I have no idea exactly how many agencies have been visited but it is substantial.  The ones that have come to my attention total approximately 15 locations with some providers sharing common ownership.

These agencies and the requested episodes are not chosen by mistake or randomly.  The Zone Contractors have been instructed to come up with innovative ways to detect billing patterns suggestive of fraud.  Before they arrive, they know which charts they want to review.   They may or may not visit the patient or the MD prior to their arrival at your agency.  There are rumors that I have been unable to substantiate that some staff members have been followed to determine if patients are visited and how long the employee stayed in the home.

How should you respond if visitors arrive at your office?  Here are my suggestions for what they are worth. 

  1. Do not panic.  They are contracted by Medicare and have every right to be in your agency.  They are there to do their jobs and no amount of attitude will get them to leave.  Be nice.
  2. Ask politely to see identification if they do not offer it right away.  Get the names of the individuals and write them down.  If they do not offer identification, call the Zone contractor for your area and verify that they are supposed to be there.  If you do not know the name of your zone contractor, look it up now and be prepared.
  3. Alert your administrator, your compliance officer and the DON that you have visitors.  Nobody else needs to know.  Quietly ask all unnecessary staff members to exit through the back door but advise them that they are to respond to any calls from the office stat.
  4. A list of episodes will be provided to you.  Assign one or two staff members to collect the documents and bring them to the DON or designee.
  5. The only review that is possible is a review for completeness.  Make sure that all notes are present.  If aide notes are missing, that is bad.  If skilled visits notes are missing do your best to find them.
  6. If you work at one of those agencies that is not above adding a date to legal document after the fact or signing someone else’s name, be aware that I have no use for your agency.  Also be very aware that you do not know what the Zone Contractor has already seen.  
  7. Number the pages and make two exact photocopies at the same time.  That way if something is missing, it is missing from both copies.  
  8. Ensure that senior management is present.  Nothing impresses your payor sources less than an owner or administrator who cannot be found while their agency is under fire.
  9. If you cannot locate visit notes or if upon a cursory review you find that claim should not have been billed (no signed orders or missed visits mistakenly logged as visits), back out the claim and include the paperwork with the information given to the zone.
  10. Do not make small talk with the Zone Contractor.  That pretty much never works out.

You do not have time to complete a clinical record review on 30 charts.  You will have the opportunity to supplement your information in the first two rounds of appeals and most agencies go at least two rounds.  Regardless of the quality of your records, expect a high rate of denials.  Also, expect that nothing will happen fast.

After they leave, go about getting caught up from what amounts to a day of not tending to your business.  Within the next week begin reviewing the photocopies you sent to identify your vulnerabilities.   Start supplementing documentation and gather supporting documents for any arguments you may produce.  When the results finally arrive, you will  be up against a deadline.

If your agency is blatantly fraudulent, get your billing caught up because the Zone can and will suspend payment if they find evidence of blatant fraud.  If your agency is not blatantly fraudulent, expect that within a year you may have your payment temporarily suspended for a few weeks after the second level of appeal and before an Administrative Law Judge.  Stack some bills now and get your creditors paid off in preparation for that time.

Remember, if things get tough, we can help you.  We have more than enough experience in appealing denials.  We have a great record with some clients and a pretty awful record with others.  You can probably guess what the difference is between the two groups.

Blue Moments

This story was posted on Facebook by a friend and I looked around to see who wrote it.  Initially, it was written off as an urban legend with a Chicken Soup for the Soul twist.  As it turns out, it was originally written by a man named Kent Nerburn in his book, Make Me an Instrument of Your Peace.  He calls these moments ‘Blue Moments’ where brilliant light shines through through the ordinary moments in our ordinary days.

A NYC Taxi driver wrote:

I arrived at the address and honked the horn. After waiting a few minutes I honked again. Since this was going to be my last ride of my shift I thought about just driving away, but instead I put the car in park and walked up to the door and knocked.. ‘Just a minute’, answered a frail, elderly voice. I could hear something being dragged across the floor.

After a long pause, the door opened. A small woman in her 90’s stood before me. She was wearing a print dress and a pillbox hat with a veil pinned on it, like somebody out of a 1940’s movie. By her side was a small nylon suitcase. The apartment looked as if no one had lived in it for years. All the furniture was covered with sheets.  There were no clocks on the walls, no knickknacks or utensils on the counters. In the corner was a cardboard box filled with photos and glassware.

‘Would you carry my bag out to the car?’ she said. I took the suitcase to the cab, then returned to assist the woman. She took my arm and we walked slowly toward the curb.  She kept thanking me for my kindness.

‘It’s nothing’, I told her.. ‘I just try to treat my passengers the way I would want my mother to be treated.’

‘Oh, you’re such a good boy, she said. When we got in the cab, she gave me an address and then asked, ‘Could you drive through downtown?’

‘It’s not the shortest way,’ I answered quickly..

‘Oh, I don’t mind,’ she said. ‘I’m in no hurry. I’m on my way to a hospice.
I looked in the rear-view mirror. Her eyes were glistening. ‘I don’t have any family left,’ she continued in a soft voice..’The doctor says I don’t have very long.’ I quietly reached over and shut off the meter.

‘What route would you like me to take?’ I asked.

For the next two hours, we drove through the city. She showed me the building where she had once worked as an elevator operator.  We drove through the neighborhood where she and her husband had lived when they were newlyweds She had me pull up in front of a furniture warehouse that had once been a ballroom where she had gone dancing as a girl.

Sometimes she’d ask me to slow in front of a particular building or corner and would sit staring into the darkness, saying nothing.  As the first hint of sun was creasing the horizon, she suddenly said, ‘I’m tired.Let’s go now’.

We drove in silence to the address she had given me. It was a low building, like a small convalescent home, with a driveway that passed under a portico.  Two orderlies came out to the cab as soon as we pulled up. They were solicitous and intent, watching her every move.  They must have been expecting her.
I opened the trunk and took the small suitcase to the door. The woman was already seated in a wheelchair.

‘How much do I owe you?’ She asked, reaching into her purse.

‘Nothing,’ I said
‘You have to make a living,’ she answered.

‘There are other passengers,’ I responded.

Almost without thinking, I bent and gave her a hug.She held onto me tightly.
‘You gave an old woman a little moment of joy,’ she said. ‘Thank you.’  I squeezed her hand, and then walked into the dim morning light.. Behind me, a door shut.It was the sound of the closing of a life..

I didn’t pick up any more passengers that shift. I drove aimlessly lost in thought. For the rest of that day,I could hardly talk.What if that woman had gotten an angry driver,or one who was impatient to end his shift? What if I had refused to take the run, or had honked once, then driven away?

On a quick review, I don’t think that I have done anything more important in my life.

We’re conditioned to think that our lives revolve around great moments.
But great moments often catch us unaware-beautifully wrapped in what others may consider a small one.

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