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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.

Unbelievable


There comes a point when you are in this business long enough that you think you have seen everything.  Today I saw something that I never even thought existed.  A long term client received their ZPIC results from AdvanceMed.  In my life, I never thought I would see anything like this.   

Make no mistake.  This is a good client who acquired an agency several years ago and then called me to look at it.  I explained that most people performed due diligence before buying an agency.  As luck would have it, it was a great agency but once sold, there was nobody there who knew the business side of homecare and they were a little less than profitable.

So after a few months, a new administrator was hired.  She has an MBA but she sold drugs prior to accepting this position. (She will read this and get mad if I do not clarify that she sold pharmaceuticals.)  The only home health experience she had was well, frankly, none.

One of the first things I did was encourage her to pay her staff per visit instead of hourly because their overall productivity was about 2 visits per day.  That was a mistake.  I should have told her exactly how much to pay per visit.  But, I left that open and so she pays her nurses a ridiculously high per visit rate.  Her field nurses make more than I do and they only work three days a week.

And because they are down the bayou, their length of stay is about the twice the national average and they have a lot of therapy.  It is difficult to educate people who have never been to school and South Louisiana is known for its large Catholic families so lots of repeat teaching is needed as family members rotate in and out.   Two of their largest referral sources are orthopedic surgeons and as such an enormous amount of their patients require therapy. 

So what do these overpaid nurses with time on their hands do all day?  They talk on the phone and write stories.  They love the copy machine so they make copies of pretty much every piece of paper they can find and give it to people.  Then they call the people they gave them to just to be sure they got them.  They play with scissors and tape and send all these lengthy faxes to the MD with the med profiles taped on them so the doc can see everything they are taking.  I keep trying to show them how to cut and paste the meds on the faxes and remind them that even if the computer explodes, they will still be able to get to their documents.  I cannot begin to imagine what they spend on paper. 

Once or twice a week, they all sit down and have lunch together and talk about their patients in case conference.  This of course is documented.  It is rare that at least one or two nurses don’t come to the office to chart in the afternoons.  The geography is such that it makes more sense to chart in the office since they turn their notes in timely.  (What else do they have to do?)  In fact, some of the most entertaining reading I have done in the past year has been in their charts.  I am still on the fence about how much is appropriate to chart about the infected penile prosthesis but I know more than I wanted.

Probably the owners would take exception to their over paid, underworked employees but since they were making money they never really noticed.  And because they were paid per visit, it didn’t really cost them too much.

They are my only client who as had a deficiency free survey in the past several years.

And their ZPIC result?  AdvanceMed determined they were overpaid by a little less than 2 percent*.  

I am in awe. 

There are lessons here to be learned unless you are my client in which case, there is a well deserved good night’s sleep waiting for you.  Pleasant dreams.

 

*For those of you unfamiliar with the ZPIC process, most results are well over 50 percent and I have yet to see an overpayment assessed at less than a million.  This agency’s overpayment was measured in tens of thousands.

Thanks AdvanceMed!


Still working a ZPIC so I am short on time to keep you up to speed.  Luckily, AdvanceMed has done most of my blogging for me tonight.  On a spreadsheet from the Zone, there is a column for the reasons for denial.  Below are some examples.  Read your charts and see if maybe one or more claims could be denied for the same reason.  If the answer is yes, it isn’t too late to do something about it.  Call us!

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The nurse continued to visit for observation and assessment when there were no acute changes in condition and no changes in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. There had been adequate time since start of care of XXXXX to have completed teaching in previous episodes. The medications:  glimeperide, quinapril, atenol, and aspirin are indicated as new on the 485; however, there is no skilled service documented related to these medications.

The documentation provided does not support that skilled nurse visits are reasonable and necessary. The SN continued to visit for observation and assessment when there was no acute change in condition, no new orders, or change in the plan of care. There has been sufficient time since the start of care of xxxx to complete the teaching that was provided in this episode. The documentation provided does not support an exacerbation of the diagnoses as indicated per the 485. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation provided does not support an exacerbation of the diagnoses.

The skilled nurse continued to visit for observation and assessment of patient’s condition when there was no acute change in condition, and no new orders or change in the treatment plan. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided. The documentation does not indicate that there is likelihood of a change in patient’s condition that requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures. The records provided do not support an exacerbation of the diagnoses as noted on the 485, or a severity rating of 4 for the arthropathy diagnosis. There has been sufficient time since start of care date of xxxxx to complete teaching.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. Sufficient time has been allowed to accomplish teaching in previous episodes since the start of care date of xxxx. The nurse provided teaching related to a medication that was not new or changed. The nurse continued to provide observation and assessment when there were no new orders or change in the plan of care. There was no documentation of any complicating factors or inherent complex services that would require a skilled professional to be safely and effectively provided.

The documentation provided does not support that the skilled nurse visits are reasonable and necessary. The skilled nurse provided teaching on hypertension, fall precautions, range of motion exercises to help joint pain and relieve pressure on bony areas, low sodium diet, taking all meds as ordered, and ways to keep BP down. There has been sufficient time since start of care of xxxx in which to have completed this teaching.

So, there you have it.  What you are looking at represents about 2M dollars in denials.

Questions?

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