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Bad Blood


I know Elizabeth Holmes. Chances are you do, too.

I have never met her or spoken with her but I recognize her. I see some former clients in the pages of John Carreyrou’s, Bad Blood: Secrets and Lies in a Silicon Valley Startup. Holmes has the distinction of being the youngest female billionaire but fraud evens out the playing field. Right now she is worth about nothing and Theranos, her company, is but a memory.

Theranos was going to revolutionize the lab industry with a device that would run over a hundred lab tests with blood from a single fingerstick.

My first thought was who needs that much information?

It doesn’t matter who needed it because it never worked. In order to use the blood, the sample had to be diluted and that never turns out well when there are tiny variations in concentrations of very little blood causing major deviations in results.

Reading Carreyrou’s book was like reading a clinical record of a psych patient without authorization. Elizabeth Holmes had but a passing acquaintance with the truth and it’s anybody’s guess where her fantasies stopped and her lies began.

It helped that she was very well connected. Her board of directors could take down small countries before lunch just for fun. Henry Kissinger, George Schultz, Sam Nunn and more believed in her. George Schultz’s grandson, Tyler worked for Theranos for a period of time that ended with estrangement from his family and almost a half a million dollars in legal fees.

As far as employees went, she hired the best but nobody lasted. Problems brought to her attention about the product not working were met with the proverbial axe. Others had a life outside of work and that was clearly contrary to the company’s unwritten policy. They quit.

Can you imagine hiding your operations from CMS auditors?

When an employee on leave committed suicide, Theranos barely recognized the employee’s absence. When her idol, Steve Jobs, died, an Apple flag was flown at half mast outside of Theranos.

Anyone who has ever worked for a fraudulent agency will recognize Theranos. I am sure that every one of her former employees is embarrassed for having believed in her ‘vision’. All of them can see the lies in hindsight and are kicking themselves for not asking the hard questions earlier. There should be an address to send sympathy cards to former Theranos employees.

If you haven’t ever had close contact with a truly fraudulent employer, read Carreyrou’s book and maybe you never will. But don’t count on it.

What are you doing for others?


“Life’s most persistent and urgent question is, “What are you doing for others?'”

Today is the celebration of Martin Luther King Jr.’s birthday. Some of us will go to work as usual and others will enjoy a three day weekend and the majority of us will remember Martin Luther King, Jr. as someone who shaped our nation and inspired us to be better people. I know that he was not perfect but that’s okay. What he stood for and taught was perfect. According to the internet, even Mother Teresa and Gandhi had flaws.

As healthcare workers, we can answer the question posed by King on a daily basis. What are we doing for others? We take care of sick people; elderly people; the most vulnerable individuals in society. We have noble professions. We save lives and help people die peacefully in their home surrounded by family and friends when the time comes. We are compassionate. The support staff that ensure that nurses continue to have the ability to take care of patients are equally as important. We have answers to Dr. King’s question.

But can we do more?

In the spirit of Martin Luther King’s devotion to equality for all, we need to recognize that Healthcare disparities are very real. I am not talking about genetic factors that predispose various races and ethnicities to certain conditions but rather how long it takes someone to receive help and what happens after they are diagnosed.

Black Americans are three times more likely to have a leg amputated related to diabetes than their non-hispanic white counterparts. Areas in the rural south are most vulnerable. I did not need a study to reveal that little secret. The study alluded to the fact that Black Americans are less likely to have their total cholesterol screened and seek treatment later. Another study revealed that they are often checked for diabetic retinopathy later. Still more surprises.

The American Cancer Society reveals that the cancer death rate among African American men is 27% higher compared to non-Hispanic white men. For African American Women, it is 11% higher than non-hispanic white women. This study didn’t allude to any underlying cause but I doubt it has to do with early diagnosis or prompt treatment.

Hispanics have higher rates of cervical, liver, and stomach cancers than non-Hispanic whites.

Non-hispanic whites have a much higher incidence of death from heroin overdoses.

The list goes on as most of you know.

Martin Luther King, Jr. also said, “If I cannot do great things, I can do small things in a great way.”

If you are unable to establish equality in healthcare for everyone, start with your patients. For some, that might mean writing a list of screenings to take to their MD so they can be ordered or results reported to the agency. It might mean arranging transportation for Medicaid patients because getting to the doctor is difficult for rural patients. You might include the family in teaching about exercise to improve circulation to the lower extremities and even encourage them to walk together (because you nailed diabetic foot care). Learn some of the ethnic foods eaten by your patients and help your patients determine a healthy way to prepare them. Be creative. Individualize your care plans.

Statistically, your patients don’t amount to a hill of beans and the changes you effect won’t alter the statistics but your patients are not statistics. Leading a patient and their family to the changes that will forever improve the quality of their lives is a small act of greatness.

Merry Christmas!


wreath (1 of 1)

Here we are again. It’s the Holidays. For some of us, at least. Many of you are still making visits or are on call for the holidays. That’s the life of a nurse or a therapist.

It’s the time of the year for giving and you have mastered that art. When you have no more to give, you find a way when a patient needs you. You listen to the lonely wishing you could do more; not realizing that you are so valuable that you are so valuable that just listening brings comfort and joy. Yet, your children and own family get just as much of you. There will be a time when what you remember most about these times is pure exhaustion and well, happiness.

You bring relief to those in pain using your education, experience and heart. Sometimes, pain is relieved simply by medicating your patient. Other times, you understand that even a hangnail can cause catastrophic pain when your patient’s family members have better things to do than visit over the holidays. You hear the sadness of an elderly patient who has lost his or her spouse and their absence is felt deeply during the holidays. You know that Advil doesn’t relieve ten out of ten pain but the extra visit to evaluate the effectiveness of the medication will.

You intuitively know when a patient is trying to spare you the burden of working on the holiday by minimizing symptoms. They are a little less talkative on the phone or are in bed ‘just resting up for church’ in the afternoon when they are usually up and active. Their color is off and maybe you can’t put your finger on exactly what is wrong but you know it’s there and so you go looking. And just like that a patient avoids a trip to the hospital for an exacerbation of congestive heart failure.

Maybe because there are fewer jobs and more home health aides available for hire, we overlook the value of those aides who have made a career of taking care of the personal needs of our patients. Obviously they bring comfort and ease loneliness, as nurses and therapists do, but they also preserve the dignity of our elderly patients. They are ‘presentable’ when family comes to visit or when they have a physician’s appointment. Patients who were previously known as strong and agile are up in a chair and do not have to have visitors help them get up and ambulate.

During the first part of 2019, there will be changes in the OASIS dataset and payment in the current PPS system. Later in 2019, we’ll be struggling to learn a new payment system. These are critically important to our future but never forget that it is you bringing value to home health and hospice.

And to you I wish a Joyous Christmas and the best year ever in 2019.

47 Days


Every quarter, Palmetto GBA publishes the top reasons for denial and ways to prevent denials on their website. This is their advice about Face-to-Face Encounter documentation which is the second most frequent reason for denial after non-submission of records.

The face-to-face encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

Specific documentation related to face to face encounter requirements must be submitted for review. This includes, but is not limited to, the following:

  • The certifying physician must document that he/she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter
  • The documentation of the encounter must include a brief narrative, composed by the certifying physician, describing how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services
  • The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification
  • The certifying physician may dictate the face-to-face encounter documentation content to one of the physician’s support personnel to type. The documentation may also be generated from a physician’s electronic health record.

On November 1, I contacted Palmetto GBA through their website. I prefer written responses I can refer to in the future. As a consultant, I find it useful to give clients accurate advice that I can back up with references.  That kind of attention to detail gets me paid.  Specifically, I wrote:

Please review the information provided under the list of April – June HH Medical Review Top Denial Codes. Your advice states that a narrative is still warranted and says nothing about supplemental documentation. When clicking on the link to ‘General Medical Review’, it provides pre-2015 instructions. And the third link is blog post by Dr. Feliciano with a 2013 date. The first link does go to the current manual but it conflicts with the information you are providing. Since providers are being denied at an alarming rate for F2F, it is abundantly clear that correct information be Provided.

Yesterday marked 47 days after my initial email. I received the following email from Palmetto:

Thank you for your e-mail received on November 01, 2018. You wrote to us regarding F2F information. You indicated there was some conflicting information in the April – June 2018 Home Health Medical Review Top Denial Reason Codes article.

Thank you for your information. We have submitted the information you provided to the Provider Outreach and Education Department for them to review the information provided.

By way of reference, e-mails are answered within 45 business days. Anytime you need immediate assistance, please call us at the telephone number listed below so that a representative can assist you with your questions quickly. You may also use our secure eChat feature that is available on our website at www.PalmettoGBA.com/hhh.

As a Medicare contractor, it is Palmetto GBA’s goal to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service. For claim status and eligibility or to speak to a Customer Service Advocate (CSA) about more complex issues, please call 1-855-696-0705. You may also visit the Palmetto GBA eServices to view claim status and eligibility at htps://www.onlineproviderservices.com/ecx_improvev2/. For up to date Medicare news and policy information, please visit our website at http://www.palmettogba.com/Medicare. Medicare beneficiaries should contact 1-800-MEDICARE (1-800-633-4227) for assistance.

I have so many problems with this email that if they were lined up they would reach the moon. Nevermind that. Let’s get you paid.

Know that if you follow the information on Palmetto GBA’s webpage about denials, your claim will be denied because four years ago, the Face-to-Face encounter documentation guidelines changed. The Medicare Benefit Policy Manual, chapter seven, section 30.5.1.2 instructs providers:

As of January 1, 2015, documentation in the certifying physician’s medical records and/or the acute /post-acute care facility’s medical records (if the patient was directly admitted to home health) will be used as the basis upon which patient eligibility for the Medicare home health benefit will be determined.

This does not mean that you may not use a traditional F2F form or attestation statement and the physician can write as much as he or she wants as a narrative, but even if it is perfect, your claim will not payable unless you also submit the physician or hospital documentation. Furthermore, the dates must match. If the physician inadvertently dates the form on the day he signs it instead of the date of the encounter, the documentation will be invalid. The physician names must match, too. If a qualified practitioner other than the certifying physician performs the encounter and prepares the documentation, the certifying physician should sign or initial the documentation to demonstrate that the information was communicated to him or her.  (A link to the manual follows this post with complete instructions.)

I see nothing in Palmetto GBA’s instructions about hospital documentation.  I see nothing in the coverage manual about a narrative.  

I do not feel good about pointing out Palmetto GBA’s lack of response to what I believe to be a legitimate concern on the internet.  Then again, I absolutely hate to see claims for excellent care provided by eligible beneficiaries denied because of stupid stuff. When agencies are taught stupid stuff by the contractors responsible for paying their claims, I get angry. Worse is when contractors are contacted and they take 47 days to say they are passing on my question to a different department. It took 47 days to forward an email? All of that kind of negates the claim that Palmetto GBA’s goal is to continuously improve Medicare customer satisfaction through the delivery of high quality and cost-effective customer service.  Have Mercy!

For complete instructions regarding the Medicare requirements for documentation of the face-to-face encounter, go to section 30.1 in the coverage manual found at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf.  If you are new to home health, take a minute and familiarize yourself with sections 20, 30, and 40.

Documentation Bloopers


I have an old file of documentation that I have saved especially for you.  These examples are many years old and I have taken great care not to disclose the agency or individuals responsible for this documentation.  Note that these are not my regular clients and I was hired to read the charts after the agency was called upon to submit charts for a ZPIC.  Also, the agencies from which this documentation originated are no longer with us and many of the nurses no longer have licenses.  They were not victims of an overarching regulatory body.  They were victims of themselves.

You may have questions about the clinicians who wrote these notes as I do.  More importantly, where were the checks and balances that ensured that the care was delivered to the patients was sound and documented appropriately?  I could comment and question indefinitely, but you’ll probably see the same thing.

1.       SN instruction given on measures to control hypertension check your blood sugar at least once a day and exercise to lower your blood sugar unless you are sick or have a blood sugar over 240 mg to prevent further complications.

The instruction to control hypertension may include checking blood sugars if the patient has diabetes.  The patient did not.  Exercising once a day may be out of range for most home health patients.

2.       SN assessed all body systems. VSS.  Pt c/o weakness, states I hurt all over.  No meds taken for pain.  SN instructed on factors that increase risk for HTN:  high na+ intake, high cholesterol intake, obesity & sedentary life-style.  Pt verbalized understanding.

This nurse at least tried to follow the care plan.  Could this be the result of a manager demanding that nurses follow care plans?

3.       Instructed if you have any problems with this med go back to ER because we don’t have an order from Dr.

Really?  I wonder if the Doctor had a phone number the nurse could use.

4.       Vitamin A and D ointment topical 1 PO for 7 days.

Sadly, this was repeated over 7 episodes.  Sometimes, it is easy to determine who is reconciling meds on a per visit or per episode basis.

5.       Pt awake and alert but forgetful sitting up in recliner with legs hanging.  Edema noted to BLE.  Slow ambulation assessed.  SN instructed pt to be aware of possible complications of osteoarthritis; Gastrointestinal bleed and stress ulcers.

At first I thought that one little word was missing as in ‘…. be aware of possible complications of osteoarthritis meds….’  A closer look at the chart showed no NSAIDs or arthritis meds.  Still, maybe she took ibuprofen by the boatload and the nurse didn’t deem it important to add over-the-counter meds.

6.       SN assessed all body systems.  VSS.  Denies any discomforts at this time.  SN instructed in possible complications of HTN:  kidney failure, stroke & heart disease.

This patient was on dialysis and had coronary bypass surgery but apparently the nurse was directed to teach only from agency approved teaching guides.  Note that there was no action for the patient to take.  The nurse went into the home and told the patient all the ways he could die and then left.

7.       SN assessed all body systems.  VSS.  SN instructed patient if any problems occur to call 911 or go to ER. Patient verbalized understanding.

Why even bother to send a nurse between ER visits?

8.      Pt is very anxious.  His hands shake – stated he has got to see paleontologist[i] next week.  Client exhibits severe knowledge deficit regarding his disease process and TX regimen.  He is very forgetful and depends heavily on caregiver to assist with his care.  He is highly potential for acute complications of his disease process.  SN to monitor closely and intervene as needed.

Besides the amusement factor of a patient visiting a paleontologist, this was found on four care plan summaries in a row.  With spell check and predictive text, etc., errors happen.  They are corrected when in an agency with checks and balances.

These agencies have other things in common.  Most are making less money than if they hired a couple of extra nurses and employed managers who did not overload their nurses.  Their billing was perpetually late and mistakes in billing were not addressed.   There was a culture of blame instead of support and compliance.  They are owned by people blinded by greed.

I like making money.  I’m sure that you do, too.  We are so lucky to earn our living in an industry that allows elderly patients to remain in their homes and our take-home pay is so much more than a check.  Meanwhile, remember that the real reason for documenting is so that the nurses, therapists and physicians who take care of the patient after you do have access to a true and complete account of the care the patient has received.

Oh, and a Lamborghini has never made anyone’s life better unless they were an Italian race car driver.
[i] I hope nobody was insulted because I linked to the definition of ‘paleontologist’ but I had to look it up the first time I saw it just to make sure I wasn’t slipped LSD.  The definition did not reassure me.  At all.

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