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Posts tagged ‘ADRs’

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.

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.

Getting Paid Part 2


Do the Right Thing

This isn’t some super moralizing appeal to your conscience to stop forging signatures or lying about visits you didn’t make.  Those kinds of people do not come here for news and information.  This is more of an appeal to nurses and clinicians to follow orders.

In the past several weeks, I have read many instances of nurses charting about why they did not do the right thing.

One of the most frequent excuses for a weight that is out of range and the nurse writes in parentheses that she used a different scale.  What does that tell you?  Here’s what it tells me:

  1. She does not know what the patient should weigh
  2. She has no idea if the patient is better or worse than before
  3. She did NOT follow orders
  4. She may be costing the agency money by setting her employer up for denials

I read a note last week that state the patient’s blood sugar was 370 but the son had only just now given insulin.   There was a note that the patient ate breakfast but no MD notification.  I suspect the patient eats breakfast regularly.  The question is whether or not the son is always able to give insulin timely.  If not, maybe a different kind of insulin would be better for the patient.

I have read may notes where the blood pressure exceeded either the MD parameters or just common safe practices and the nurse charts that the patient hasn’t had their medications yet.

In other words, nurses are spending time explaining away why they did not follow the care plan when they should be notifying the MD.  Maybe the blood pressure is extremely high every morning before medication. It certainly is more convenient if the patient strokes out in the morning but that is not a reason to let a patient’s pressure pound against their arterial walls every morning.

In order to get paid you must do the right thing.  If you do not communicate with the physician and if the care plan does not change, your patient is no longer eligible for services.  Explaining why YOU didn’t follow orders is not a billable skill.

Again, here is the language that I read repeatedly when appealing denials:

The records provided do not support that the skilled nursing services were reasonable and necessary for the treatment of an illness or injury. During the last certification period, there were no exacerbations, injuries or new diagnoses that would require continued skilled services.

Any questions?

Remember, answering to us is a lot more fun than answering to Palmetto or the Zone when you get ADRs.  And if you do get ADRs after reading this, I respectfully reserve the right to say, ‘I told you so’.

Getting Paid Under Scrutiny


In between hurricanes and frightful traffic, I have been fighting for money that other people want to take away from my clients.  My first intention was to show  you the language typically used in the denials I have been seeing from the Zone and the MACs.  Then it occurred to me to show you what was written when the claims were allowed.  This might be of greater value.

Medicare guidelines for reimbursement have been met. Patient received physical therapy services due to recent fall and weakness. Skilled nursing services for medication changes and observation and assessment of disease process. Therefore, it is allowed.

Medicare guidelines for reimbursement have been met. The patient required medication changes related to her hypertension and hyperkalemia. Therefore, the episode is allowed.

Medicare guidelines for reimbursement have been met. The patient had multiple medication changes related to blood pressure fluctuations that required monitoring. The skilled nursing services are approved.

Skilled nurse visits allowed due to patient requiring skilled nursing assessment and observation. Pt had upper respiratory symptoms and was started on prednisone and phenergan expectorant cough syrup. Documentation meets Medicare criteria for reimbursement.

There were plenty other claims paid.  Some were paid because the patient went into the hospital for heart failure of renal disease.  I did not use those as an example because it is not sound clinical practice to induce an exacerbation for payment purposes.

The difference between these claims which have been allowed and those which are denied begins with the nurse in the home.  Three things must happen in order to rightfully claim that an exacerbation has occurred.

  1. The patient’s condition must change.
  2. The nurse must communicate the changes to the MD
  3. The plan of care must change as a result of the changes

The nurses whose documentation resulted in payment above did not get a blood pressure of 160/95 and write it off to the fact that the patient just walked down the driveway to get his mail and ignore it.   They don’t just assume that everyone has allergies this time of year and make a note to check on the patient again next week.  These nurses may be very friendly but they do not make visits that only social in nature.  They take the time to communicate changes, get orders and document.

More important than surveys and payment is that this careful attention to patients results in better care.

The parameters that are not mandated but are shown to be good practice when writing care plans can be an invaluable tool.  Everything else aside, if your patient exceeds parameters by only a fraction and you do not call the MD, you have not followed orders and that results in a survey deficiency.

When you communicate with the physician, have all the information required.  What has the blood pressure been over the past several weeks?  Is there anything else going on with the patient?  Were there any med changes?

Here is a visit note written in a claim that was denied.

take meds as directed

I am horrified that one of my peers actually accepted money from her employer for this level of nursing.  It does not require the skills of a licensed nurse to tell the patient to take meds exactly as prescribed.

Agencies can implement all kinds of strategies, hire the best consultants (if we’re available), set arbitrary visit rates and lengths of stay but unless the nurses visiting the patient take the time to really take care of the patient, it is all for naught.

But if you have good nurses, we can and will see you through a little regulatory scrutiny.

Be sure to drop me an email if you are getting any strange ADRs.  I am particularly interested in those with a reason code of 5Z5NP.

Deny, Deny, Deny


This horse will likely die of humiliation soon but please don't beat her. Her owners have put her through enough already.

It’s Mandy here.  Hope you all had a wonderful holiday.

So, we all know the old saying – Deny, Deny, Deny.  Well, apparently that’s what our zone contractors are so anxious to do.  They deny claims for the smallest little things like medical necessity. Whoever heard? Wink, Wink.

The truth is, these zone contractors get paid literally millions of dollars for ensuring that claims are paid appropriately. In order to make CMS feel good about al those millions of dollars, they have to offset the payment with a whole lot of denials. I wonder how they sleep at night?  Probably, pretty good laying on their big fat wallets.

But it doesn’t stop with the Zone.  Apparently, Palmetto and other MACs got jealous at all the attention the Zone contractors were getting and now they are flooding the market with ADR’s.  In some cases, the same agencies under a ZPIC audit are also getting ADR’s.  How can that be fair?  It probably isn’t, but we ain’t changing it so we have to live with it.

Palmetto GBA is so warm and fuzzy; they give us a list of the worst offenses.  Here are the most recently listed Top 10 reasons for denial:

    1. Documentation does not support homebound status.
    2. Lack of response to ADR.
    3. Information does not support medical necessity.
    4. Orders do not cover all visits billed.
    5. Unable to determine medical necessity b/c appropriate Oasis not submitted.
    6. Medical review HIPPS code change/Documentation contradict M item/s
    7. POC/Cert present and signed but not dated
    8. Dependent services denied because qualifying service was denied.
    9. Partial denial for therapy resulting in medical review HIPPS code change.
    10. Order not signed and/or dated timely.

What are we dealing with here?  Homebound, medical necessity, we know, we know.  Apparently, we don’t.  50% of this list is directly related to documentation.  Whether it be our Oasis, our skill, or our therapy notes, can we beat this dead horse anymore?

Attention DON’s and case managers! Calling all nurses and therapists! 

Big brother is watching.  We can no longer skate by with the minimum.  We must provide top notch care with top notch documentation EVERY, SINGLE visit for dwindling reimbursement.  What does that mean?  Only the best will survive, but we can do it.

Steps to take to alleviate denials:

  • Train staff based upon the most current guidelines not outdated belief systems
  • Make sure employees understand the definition of homebound status and how to document  it on every clinical note, including therapists
  • Don’t provide an opportunity for a medical necessity denial
    • Actually look at medicines every visit – truly groundbreaking idea
    • Develop working relationships with physician offices to open communication
    • document all changes to the plan of care
    • document all changes in condition
    • Ask for changes to the plan of care when necessary.
    • Always address caregivers in documentation – preferably by name.  Changes in caregiver status affect our patients.
    • educate all clinical staff to sign and date notes with a legible signature if you are not using electronic documentation
  • Train clerical staff to look for signatures and dates when filing as a double check system
  • Establish a follow-up policy for outstanding orders and stick to it.  Orders not signed within 30 days are not acceptable.  Hand deliver to the physician office if necessary.
  • Get a custom stamp that reads:  DATE YOUR SIGNATURE or something a little less subtle to put on MD orders and care plans

Everyone makes a few honest mistakes, but more than a few could land you in the slammer.    Be careful out there my fellow warriors.  Document, document, document!  Our nursing instructors were right!!

*Please note: No horses were actually hurt in the writing of this blog and I have never actually spoken to or met a zone contractor employee so I actually cannot vouch for their sleeping arrangements, personal appearances or opinions regarding home health zpic audits.  This is only a commentary and represents no actual employees of Zone Contractors.

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