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Mar 26

6 Comments

Skilled Charting

Our small little company probably sees more denials than anyone else other than say Palmetto or one of the Zone contractors.  So we make a lot of fuss about documentation and getting paid but while we are very good about finding errors, we don’t offer as much as we should in teaching documentation with payment in mind.  I’m not going to bother with that now as I have a lot to do so let me just show some examples of bad, better and really good documentation.

Skilled Teaching – Diet

Bad:  taught low sodium diet.  (worse if this is not the first time)

Better: Taught patient how to read food labels for sodium content.  Used handout attached.

Best: Taught American Heart guidelines for low sodium diet according to handout pages 1 and 2.  Copy attached and left in home folder.

Homebound Status

Bad:  SOB on exertion (everyone gets short winded if they exert themselves enough)

Better:  Patient is short of breath when walking 20 feet.

Best:  Patient is unable to leave the home due to SOB r/t CHF, arthritic pain and impaired judgment due to narcotic medications.  Requires cumbersome assist devices and at least one person to help leave the home.

Diabetes Foot Check

Bad:  Taught patient to perform foot care.

Better:  Inspected all surfaces of feet.  No problems noted.  Patient was able to demonstrate foot care with a mirror.

Best:  Inspected all surfaces of feet while simultaneously instructing patient on foot care and (proper footwear), (risks of decreased sensitivity), (risks of going without shoes), (when to see podiatrist), (importance of annual eye exam).  Take your pick and rotate through the list.

PT/INR

Bad:  PT/INR drawn per orders and brought to lab.

Better:  PT/INR drawn per orders.  Called team leader to watch for results.

Best:  10:00  PT/INR drawn.  Dosage of 5 mg/day Coumadin noted on lab slip.  4:00 pm  MD confirmed receipt of lab.  INR 2.8.  No new orders.

Any0ne else care to add to the list? Yes, you’ll chart a little more but if you blow off the recap of what is on the flow sheet – assessed all body systems, patient awake alert and oriented times 3, denies pain, etc., etc., you may find that you write less and say more. Better yet, you will get paid for your hard work and your outcomes will improve as well.

Mar 13

3 Comments

Patients for Sale

I sound like a broken record reporting on fraudulent activity so often these days.  It really is not what I want the focus of this blog to be.  Normally I would not report on a fraud conviction related to a partial hospital program, sleep clinic, etc. but I think we all need to pay attention to why these people are going to jail.  From the HHS press release:

According to court documents, ATC’s principals paid kickbacks to owners and operators of assisted living facilities and halfway houses and to patient brokers in exchange for delivering ineligible patients to ATC and ASI.  In some cases, the patients received a portion of those kickbacks. 

What this means to you is that if you or your agency enter into any agreement where cash or goods are provided on a per referral basis, you may find yourself in jail.  My recommendation is that any arrangement where someone is paid a bonus for referrals be reviewed by a healthcare attorney.  If you choose to ignore my advice, please at least consider the following advice.

  1. When selling patients, charge a lot more than $50.00.  There are hidden costs in this line of work including legal fees and bail money.  Do NOT accept checks or credit card payments when selling patients.
  2. When buying patients, at least give them a token amount of health care.  I am petitioning God for a special kind of hell for those that bill on our most vulnerable members of society and don’t even give them much needed health care.
  3. If your generosity to patients includes flat screen televisions, cash, WalMart cards or rides to the physician’s office, have the patients sign a confidentiality agreement first.
  4. If you pay an outrageous amount of money for rent to another facility so you have access to their patients, make all payments in unmarked bills.
  5. If you market directly to patients, wear a disguise, drive an grey sedan and use a fake name.  Do your marketing before 8:00 am and after 5:00 pm.  The feds keep a pretty predictable schedule and you will be less likely to draw attention.  

Of course, the best way to market is to provide impeccable care and become known as the agency who keeps patients out of the hospital and goes further than other agencies to attend to patient needs.  It has come to my attention that some agencies are unwilling to go that route.  If you are one of them, heed my advice.  You will still be caught but you may have a little bit of cash stashed away for legal fees.

Feb 29

Payment Suspended for 78 Agencies

By now, everyone has heard of the very busy Dr. Jacques Roy who had more home health care patients than anyone in the entire united states and is accused of causing greater than 345M in false claims to be billed to Medicare.

Have you read the actual indictment, though?  It names at least two RN’s as well.  That really doesn’t bother me because I don’t count nurses who pay homeless people money as colleagues.  I do so hope they lose their licenses.

What was tucked in at the bottom of the most recent article that came across my desk is that 78 home health care providers have apparently had their payments suspended pending the results of a full investigation.

This sounds extreme and it is because of the number of agencies that have payment suspended.  However, these are  not the first agencies who have had payment suspended because of ties to known or suspected physicians.

One client was assessed an overpayment of greater than 3M.  This is small time compared to the 345M that makes headlines.  Nevertheless, payment was suspended.  Another agency with the same medical director likewise had their payment suspended.  The second agency was not in a position to hire me due to the profoundly impaired cash flow.

Check your docs, folks.  After these agencies had funds suspended I began researching the docs for all ZPIC clients.  It is amazing what was found.  The problem is that the state board of medicine doesn’t actually report on issues while they are still under investigation.  In fact, the medical director referenced above was in jail for 8 months before the OIG added her to the exclusion list.  The state board of medicine still lists the license as active and having no disciplinary history.  (Jail doesn’t count, I suppose.)

I got the good stuff the way I get all the good stuff.  I googled the docs.  The press love photos of physicians being escorted out of buildings by men in uniforms.  If there are handcuffs involved, it makes the first page.

If a physician has a restricted license, be sure that you are fully aware of the restrictions.  Some physicians in recovery are not allowed to prescribe scheduled meds.  Often a nurse will write all meds a patient is taking including scheduled meds from another physician.  When the restricted doc signs the 485, he has just violated his license.  I had never come up against that before and frankly, I do not know how these will fare during review.  I am not hopeful, however.

For what it is worth, the client who was assessed the greater than 3M overpayment arranged to borrow the money from the bank so that Medicare could be paid back and the agency would be able to function until the appeals level of the audit.  Medicare said, ‘thanks but we are not restoring your payments until after the entire investigation is complete.

In other words, a year or longer.  That means that there are effectively 78 fewer agencies in Dallas this week.

On the bright side, you may get a really good deal on a licensed only agency but you will not be able to bill until you establish a new provider agreement with Medicare.  Remember, if you purchase a provider and assume their provider agreement, you have assumed their debt to Medicare.  You would think that would be obvious but it’s worth stating again.

So, check your docs.  If you find out any good stuff about docs in my area (Louisiana, TX, Fl, AL), send me a discreet email at julianne@haydelcs.com so I can ensure my clients are not unwittingly involved with someone who will get their cash suspended.

Feb 17

20 Comments

Foot Assessment Tutorial

It is not my style to knock the advice given by the American Diabetic Association, Podiatrists, the Lower Extremity Amputation Prevention Program or all of those other so-called experts who teach foot exams.  I certainly buy into their position that assessing feet is important for so many reasons but I find that their instructions are incomplete.  In response, Haydel Consulting Services, LLC has stepped up to the plate to provide you with the missing pieces for a complete foot exam.  Pay close attention.  The skills you learn could save a limb or a life.

  1. Start with a foot encased in a shoe and sock.  Take a look at the shoe to make sure it is appropriate for the patient and fits well.  High heels, flip flops and all the other really cool kinds of shoes are not appropriate for many of our elderly patients.  No matter how ugly the shoe is, do not criticize the patient’s choice of footwear if the shoes meet the above criteria.
  2. Untie the shoe.  This may add some time to your visit but it will definitely make it easier to complete the following steps.
  3. Gently ease the shoe off the foot.  Do not pull, tug or otherwise force the shoe off to prevent the foot from coming off with the shoe.
  4. Inch the sock down from the top towards the toes until the entire foot is visible.  DO NOT ATTEMPT STEP 4 UNTIL STEPS 1 – 3 ARE COMPLETE.
  5. Attentively assess the foot according to the incomplete guidelines published by above referenced agencies.  Notice how the nurse in this photo (Susie Soskin, RN) is at eye level with the foot.  If you cannot get down to eye level, find someone who can or get the patient to lay down in the bed.  If your knees are too old to bend down then chances are your vision is not good enough to assess feet from a distance.
  6. These are perfect feet.  I know this because they belong to my son.  I have bought hundreds of shoes for these size elevens.  At the cash register, I have often been a bit overwhelmed at the cost of keeping him in shoes.  After taking care of a few amputees, I am honored to have had the privilege to buy full pairs of shoes for him.  I hope when I am dead and gone, he still has to pay for a full pair.

A high resolution copy of the above tutorial is available by clicking here.  Please feel free to print it, share it or ignore it.  And yes, I know the vast majority of us do take shoes and socks off every visit and look at diabetic feet.  This is good but diabetics are not the only patients who benefit from foot assessments.  Patients with heart failure or take diuretics will show signs of fluid build up in their feet, compromised circulation from cardiovascular or other disease can result in discoloration or stasis ulcers and injuries to the feet can be overlooked by any patient with loss of sensation or callused skin.

So, if this helps you to remember, all is well.  If you don’t need reminding, kudos to you.  If you think that one of your nurses or coworkers is not taking the time to do a complete foot assessment, draw a happy face on the bottom of the foot and see what shows  up in the documentation:)

As always, questions and comments are welcome below or via email.  As so on…..

Feb 8

Difficult Decisions

Be honest with yourself.  Have you ever held on to a patient longer than they technically qualified for home health services because there was nobody else to take care of them?  Have you ever recertified a patient for diabetes because they had an isolated blood sugar of 302 after washing birthday cake down with coke? What about the patient who has achieved stability at rock bottom and the only alternative for the patient is a nursing home?

I can spot patients who do no longer meet Medicare coverage guidelines a mile away because of my superpowers.  Also, I am not emotionally attached to your patients so it is easier for me to be objective.

These are the facts and I do not like them one little bit:

  1. Observation and assessment is a skill for only a short period of time (generally 3 weeks) unless there is documentation to support why the patient remains at increased risk.  This means stuff like actual falls and changes to the plan of care.  Headaches during allergy season that are controlled with Advil do not paint a picture of increased risk.
  2. Teaching is a covered skill.  Re-teaching is only a skill if there is a documented reason why said re-teaching was indicated.  Teaching is NOT a skill when it becomes apparent that the patient cannot or will not learn.  This means that teaching an advanced Alzheimer’s patient new skills will not be deemed reasonable and necessary.  It does not matter how hard you teach someone who is unable to learn.
  3. Homebound status is very poorly defined unless you work for someone with the authority to deny your claims.  Document homebound status.  If the patient meets homebound criteria three ways, document three times.  Everyone is SOB with enough exertion.
  4. There is a space at the lower left corner of each 485 that reads, “Attending physician’s signature and date signed”.  A Nurse Practitioner, physician assistant or love interest of a physician is not a physician.  When you identify actual physicians, try to narrow your choice down to the one who actually attends to the patient’s need and obtain their signature.  A signature is when somebody write their own name in their own handwriting or uses a secure electronic alternative.  Don’t stop yet.  Get the DATE.  If you haven’t heard me rant about dates yet, it is because you haven’t been paying attention.   
  5. Sadly, home health aide services do  not qualify a patient for home health.  In the event that you admit a patient who will likely require services indefinitely, that is the day you should begin searching for an alternative. Call relatives.  Beg churches.  If the patient  has Medicaid, find waived services for the patient.  Anticipate the day you will have to leave your patient alone in the house because there are no more skills to render.

It is heartbreaking to discharge some patients.   Sometimes it helps if another nurse goes to do the dirty work.  I have taken the discharge of patient in need of services not covered by Medicare harder than I ever took a death in all my critical care years.  There’s nothing left to do for a patient at room temperature.  Lonely elderly folks with vital signs are the ones who turn my heart to mush.

Knowing what constitutes skilled care going into the house will guide you in seeking alternatives to what feels like abandoning a patient in need. Remember, the folks who do ADR’s and ZPIC reviews do not know how sweet your patient is.  They have not been seen how happy your patient was to share with you the cookies someone made for them at Christmas.  They have not heard about the way music used to be played when it was good or held your patient’s hand when they lost a spouse.  If you are a good nurse, a patient will touch your life as much as you touch theirs.

But, none of that sappiness, as real as it in our hearts will keep you out of trouble if you do not provide skilled services according to Medicare guidelines.  When you fail to follow guidelines, you put at risk all of your patients, your employees or employers, their families and the agency’s stakeholders.  Better just to start planning your exit strategy on admission, wouldn’t you think?

If you have any questions, please contact us or post below.  If you want to hire Haydel Consulting Services to discharge your lonely patients, we will be glad to do so.  Just take our regular hourly rate and multiply it by 72,761 and plan on a 50 hour minimum for discharge services.

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