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Posts tagged ‘CMS’


I admit that I was a little hopeful, if not disillusioned, when the new UPICs came to my attention.  After verifying that UPIC was not a ZPIC with a typo, I thought that maybe this was a special type of audit where you got to pick the charts you wanted to be reviewed like some people pick their own lottery numbers.  No such luck, I’m afraid.

UPICs are Unified Program Integrity Contractors.  UPICs will carry out program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching[i].  The primary objective of the UPIC is to identify fraud and abuse and make appropriate referrals.  Other agencies recoup overpayment and address recommendations to law enforcement addressing criminal or civil charges.  They can also recommend suspension of payment.  Whether or not the agency is notified in advance of the payment suspension depends on if the UPIC thinks it is possible that the provider will change it’s billing habits if it knows that payment will stop.  Think about that for a minute.  Who wouldn’t change their billing habits if they knew payment was coming to an abrupt halt?

UPICs, like ZPICs can request clinical records, verification of licensure, copies of claims, etc.  The most recent UPIC request I read included a host of new horrors that may not be available and/or are too cumbersome to send.   Here’s a short recap of some of the new things but remember, they can always ask for more or even go to your office to visit.

  1. Copy of the face sheet. I have never used this term in home health or hospice, but it is basically patient demographics and insurance information.  People who have experience in a hospital are likely familiar with this term.
  2. Copy of Medicare card and state identification card (driver’s license or state ID). The logistics of getting a copy of the Medicare card and state identification card involve too many opportunities for loss and theft that I don’t recommend it even if Medicare wants it.  However, Medicare and other payor sources lose money daily when somebody loans (rents) their Medicare/Medicaid card to someone else.  Some software systems allow you to post a picture of the patient on the face sheet.  DNA and fingerprints are not necessary, but the end of the earth is not too far to go if there are any doubts. 
  3. Authorization of benefits. This is almost universally included in the consent form given to patients.  Take a quick look and ensure that somewhere on the consent it says that the patient or representative authorizes the agency to bill Medicare for services.  It would hurt a lot if this statement was inadvertently omitted when all those changes were made to the form relative to the new Conditions of Participation.
  4. EHR Audit Trails. In most systems, these audit trails are cumbersome to obtain and require someone to print or save the audit trail for each individual document.  In one system, the audit trail can be over 100 pages for a single document.  For a long time, there was a vendor who provided audit trails on request, but the agencies were not able to run them.  If you get a UPIC, consider the burden to your agency and call the person who signed your UPIC letter.  It kind of makes paper charts seem appealing again.
  5. OASIS to include the start of care, the resumption of care certification prior to and after the dates of services noted in this request and the discharge. I’m not entirely sure what this means.  To the best of my knowledge, patients aren’t certified after Resumption of Care unless the patient was in the hospital at the end of the episode and there is no change between the recertification assessment (not mentioned) and the ROC HIPPS code.  If an agency has a reasonable hospitalization rate, this is a rare occurrence.  Plus, there are numerous other bullets in the list that mention OASIS assessments.
  6. Travel Logs. Some agencies don’t have travel logs.  Some don’t pay mileage and others pay a flat ‘trip fee’.  I would think a visit log would be more useful to the UPIC but in the two page request, that wasn’t mentioned.

There are many more entries in the UPIC request but even though the length of the list is daunting, it is repetitive.  Laboratory results are requested on page one and all diagnostic tests are requested on page two.  There are individual entries for all hospital documentation, Inpatient records, Inpatient records to support start of care, inpatient records for hospitalizations during the episode, emergency room visit notes and the history and physical.  The best advice I can give is to be careful when delegating the tasks on the list, so you don’t have multiple employees all printing OASIS assessments.

The good new is that most of you will not find yourself in the undesirable position of being the target of a UPIC. If you are one of the unlucky ones, well, it’s not luck that brought you the unwanted attention from a UPIC.  The data analytics are very sophisticated and there is nothing random about the selection of charts (which makes me wonder why a copy of your Medicare Census is included in the list of documents required from the agency.  They know who your patients are.)

That doesn’t mean that your agency is operating outside of coverage guidelines.  It does mean that cloned notes, poor coding, lack of OASIS skills and care plans that are copied from one episode to the next will be under the spotlight.  This results in paying money back to Medicare and additional scrutiny which may extend to your referring physicians who might then begin referring patients to your competitors because they don’t like attention from Medicare any more than the rest of you do.  I do not like it when care is provided to eligible beneficiaries gets denied because a nurse is a little too eager to show off his or her new cut and paste skills.  It’s not like the agency can recoup their paychecks.

Questions?  Comments?  Do you have any experience with UPICs?  Post your comments below or email us.  We need to know now so we can understand them before they become obsolete.

[i] From Noridian Healthcare Solutions

New Automated Denials Coming Soon

Today’s post is written by John M. Reisinger, CPA (TN Licensed) of Innovative Financial Solutions for Home Health Publisher of the Home Health Care Resource Planner.  His contact information follows this post.

John sent the following out in an email this morning so some of you may have already seen it but it is important enough that reading it twice is a good idea.  It speaks to a new way that agencies can be denied without a lot of trouble.  There are links to supporting information an this needs to be shared with your entire agency.

Dear Clients:

 The CMS Medicare Learning Network (MLN) released a new article on March 24 regarding the denial of payment when a Claim is submitted when there is no (required) corresponding assessment in their system.  This will have an effective date of April 1, 2017; so this is something that you want all your billers to be on top of, as well as those that manage the OASIS submission process.  (Julianne’s note:  often the OASIS is submitted but not included with ADR information when a recertification falls in the prior episode.  Be sure that the person compiling the ADR knows to go back and retrieve the recert OASIS.)

Title:  Denial of Home Health Payments When  Required Patient Assessment Is Not Received – Additional Information


This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.


In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.


Don’t cost yourself money by not paying attention to the details.  This has always been a requirement under PPS, just a loosely (if at all) enforced regulation.  That is changing effective April 1st.  Now is not the time to worry about the ‘way we have always done it’, now is the time to start doing it ‘the way it should be done’.  Hopefully your software has systems in place to identify these instances when they occur, and your billers have an understanding of how to verify what is appropriate to be billed and what is not yet ready and why (and have processes in place to share that information with you immediately).

In fact, everyone should now be moving to and focusing on ‘the way it should be done’ in all aspects of their operations instead of the‘way we have always done it’, because if things we did in the past were so good, we wouldn’t be having the troubling relationship that we currently have with CMS, MedPac, Congress, et al, that we do have.


Ph. # (813) 994-1147
Fax # (866) 547-8553


Hospice Meds and Medicare Part D

If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

First Glance at OASIS – C Guidance

UPDATE:  OASIS-C training has been scheduled for November 12th and 19th at our Education Center.  Please call 225-216-1241 for more information on how to attend or how to schedule training at your location for your clinicians.

Like many of my colleagues, I spent the day reading the official OASIS-C Guidance Manual and got the first look at the instructions that accompany the dataset. And, of course, as predictable, at least one section (wound care) has already been pulled back for review by CMS. Obviously, we are not experts on the newly published guidance but after a first view, we did make some interesting observations and hope that you will share your observations with us as well.  A link to the OASIS-C Guidance is published below.

New Dates

We have new dates to record in the OASIS dataset. Within the context of the dataset, they appear as simple data points. Within the instructions, it appears as though the dates that are recorded are going to be very specific regarding admission/resumption of care dates. The dataset wants to know if the physician ordered a specific date for admission/ROC. If, not, the dataset wants the date that the agency received the verbal or written order to admit/resume care. Physician signed updates must be present to justify any deviance from the orders or expected compliance to state and federal rules.

What this means: By running a simple data check on collected OASIS data, CMS and state surveyors now have the ability to determine how long it is taking you between referral and admission/resumption of care. More importantly you will be able to determine if your patients are being admitted timely.

Vaccination Status

Although it should be a simple task to answer the four questions on vaccination status, a quick google search told us that there was no formal flu season. It is generally accepted to be between October and May. This year we have two varieties of flu striking at two different times. Do we answer the question without regard to H1N1 flu as we can reasonably assume that it wasn’t a known threat when the dataset was written?

The second issue is that CDC guidelines are referenced in vaccination questions. This will add the burden of the agency to research the vaccination guidelines each year as changes are made. When the flu vaccine is in short supply, the age range may change. Certain populations with compromised immunity may receive additional or split doses of one or more vaccine. The only way we will be able to clearly assess the vaccination status of our patient is to be current on the CDC Recommendations. Considering that 36,000 people die each year from the flu, this may not be too much of a burden to nurses.

Standardized Assessments

There are several questions which assess an agency’s use of formal assessment tool. The use of this information is to capture the agency’s use of best practices following the admission/ROC assessment. The OASIS Guidance stresses that CMS does not mandate the use of any tool, nor does it recommend one tool over any other. Hint: CMS may not mandate the use of these tools but only an agency that does not want to succeed will ignore the blatant hint to do so.

And this isn’t a bad idea. We need to educate staff to collect consistent data during assessments across time periods so we can measure our success. After CMS will be measuring our success and publishing it for all of your referral sources, patients, state surveyors and the odd curious person with an internet connection. The only formal assessment that is actually included in the OASIS dataset is a depression screen comprised of only two questions. The first question assesses for how long the patient has been bothered by little interest and pleasure in doing things and the second assesses if the patient is feeling down, depressed and hopeless. By my early calculations, approximately all of our patients will meet the standard for depression on admission. Although it is still very early, it is likely we will search for another tool for agencies to use in place of the screen included in the dataset.


Medications are intensely assessed in the OASIS-C dataset. Again, this is a first glance, but my first impression is that the instructions provided in the OASIS-C guidance are confusing. It appears that agencies will both have to learn and to collect data on adverse events. Currently, most of our clients complete adverse reaction forms for truly serious medication errors and the dataset is asking for information on missed medications, etc.

Also, within this set of questions (as well as some others), physician notification is defined clearly. The physician notification can be by fax, phone, email, etc. but there must be verification that the physician received the communication. Whether or not orders were adjusted will also be assessed and data collected.

Moving Forward

This certainly isn’t the last you have heard from us on the new dataset and the published Guidance. We have been asked by our State OASIS coordinator not to teach prior to their training. Apparently, this request came from CMS. However, early next year come meet me in Chicago at the Ultimate OASIS-C and Coding training series presented by Decision Health. More information can be found here: training.

Again, we also want to know what you think so please feel free to call us at 225-216-1241 or email us at

Home Health Physical Therapy

Update:  The Louisiana DHH clarified on Friday afternoon that even though they expect orders and goals to be included on the care plan, it is recognized that this is not always possible.  In these instances, a separate verbal order containing all of the physical therapy goals and orders is satisfactory.  We apologize for any confusion.  Please feel free to comment below or email us at if you have any questions.

It is common for agencies to order a Physical Therapy evaluation on home health admission and wait until the paperwork has been submitted to the office to write orders for frequency, treatment modalities and goals.  These orders have traditionally been sent to the physician as a separate verbal order.  Well, most of the time:)

During a recent client survey, a state surveyor informed us that CMS now expects the orders for frequency, modalities and goals to be on the 485.  Because this was contrary to the advice we have traditionally offered to our clients, we called the Louisiana Department of Health and Hospitals.  Louisiana DHH also informed us that CMS expected all orders and goals for physical therapy to be included on the 485 and failure to do so will appear as thought the agency simply didn’t complete the care plan.

So there you have it.  Managing Physical Therapy has always been a challenge in Home Health.  We would like to hear your views on these changes.  Is this how your agency already does therapy?  Will changing to this process improve or impede coordination of care in your agency?  Or is this change so insignificant that it can be integrated into your current process without much trouble.

To leave a comment, click on the link below.  To resond privately, email us at

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