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Posts tagged ‘compliance’

More Conditions of Participation


484.55 Condition of participation: Comprehensive assessment of patients.

Most agencies will not find it difficult to comply with the requirements in the Comprehensive Assessment because they are already assessing these areas.  The fact that ‘Cognitive Status’ which is already included in the OASIS data set and ‘Patient Goals’ are now mentioned in the Conditions of Participation may be an indicator of exactly how serious Medicare is about changing their focus to a patient centered approach to care and outcomes as opposed to the more punitive approach of hunting for agencies that disregard regulations.

The biggest change regarding the Initial Assessment that I see is that the Occupational Therapist is now able to complete the initial visit if OT is the only service ordered by the MD and if the need for OT establishes Medicare Eligibility.  Welcome to the world of Admits, OT’s.

Content of Comprehensive Assessment

  • Current health; functional and cognitive status
  • strengths, goals and care preferences
  • Continuing need for home care
  • Review of all medications (Identify potential adverse reactions, ineffective drug therapy, side effects, significant drug reactions, duplication and noncompliance with meds.
  • Patients primary caregiver and other available support
    • Willingness to provide care
    • Availability and schedules
    • Patients representative if any
  • Incorporation of OASIS data

Recertification visits are still done within the same time frame (days 56 through 60 of episode).  Resumption of care visits are done within 48 hours of the patient’s return to home OR on physician ordered ROC date.

Plan of Care

Patients are accepted for treatment on the reasonable expectation that the agency can meet medical, nursing, rehab and social needs in the home.  Care plan must specify the care and services to meet specific needs identified in the comprehensive assessment.

Plan of Care contents

  • All pertinent diagnoses
  • Mental, psychosocial and cognitive status
  • Types of services, supplies and equipment required
  • Frequency and duration of visits to be made
  • Prognosis
  • Rehab potential
  • Functional limitations
  • Activities permitted
  • Nutritional requirements
  • All Medications and Treatments
  • Safety Measures
  • Risk for Emergency dept visits and rehospitalizations
  • Measures to mitigate risk of above
  • Patient and caregiver education
  • Specific interventions and education
  • Measurable outcomes and goals mutually identified by the patient and agency
  • Advance directives
  • All orders

Each patient must receive a copy of their plan of care.

Additionally, each patient is to receive written instructions that include:

  • Visit schedule
  • Med list with names, dosages and any meds to be administered by agency
  • Any treatments including those administered by agency or persons acting on behalf of agency including therapy.
  • Any other pertinent instructions specific to the patient’s care needs
  • Name and contact information of the agency clinical manager.

Revision of POC

There is nothing new here but something has been removed.  There is no requirement that a 60 day summary be sent to the physician.  It shouldn’t be needed if agencies abide by the following.

  • The plan of care must be reviewed and revised by the physician responsible for the home health plan of care at least every 60 days .
  • Agency MUST promptly alert relevant physicians to any changes in the patient condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  • Revised plan must reflect current information from updated OASIS and contain information about progress to goals.
  • Revisions must be communicated to the patient, representative (if any), caregiver and all physicians issuing orders for the plan of care.
  • Revisions related to discharge planning must be communicated with all of the above plus the patient’s primary care practitioner or other healthcare professional who be providing care for the patient in the community.

Conformance with MD Orders

  • Drugs, services and treatments are administered only upon the order of a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after assessing for contraindications.

Actions:

  • Review the way your agency handles plans of care and ensure your process includes a mechanism for dissemination of information to all physicians writing orders for a patient.  Review or develop a vaccine policy that allows for administration of flu and pneumonia vaccines according to a well-written protocol developed in conjunction with a physician.
  • Most agencies will have to expand the collection of information related to caregivers and availability.
  • Begin now to audit admissions for the requirements set forth in the CoPs.
  • Begin reviewing admissions using a tool based on the new requirements.  admission-review-tool.pdf  Modify to fit the needs of your agency.
  • Educate your staff.

More Later.  And to think, we haven’t even looked at Quality Assurance, yet.

End in Sight for Home Health Services

A guide for documenting the continuing need for skilled services in home health.

Read more

But Our Survey was Perfect!


The state has come through and scrutinized every piece of paper in your office, gone on multiple home visits and even complimented you on your Infection Control Program.  There’s absolutely no reason to be concerned when some ADRs are received from Medicare.  How could an agency as perfect as yours be denied payment?

It happens every day.  Trust me.  I hear about perfect surveys and denials in the same sentence almost every day.

State regulations often follow the Medicare Conditions of Participation.  If your survey was perfect or even just good, you have likely met the CoP’s.  However, off to the side, in another area of the manual are the Medicare Conditions for Payment.  They are separate and apart from the CoP’s because not all payor sources have these requirements for payment. 

They are:

  • The patient is confined to the home
  • The patient is under the care of a physician (or as we say in the south, under the doctor)
  • The patient has a need for recurring, intermittent skilled care.
  • A Face-to-Face Encounter must occur within a designated time frame
  • The patient is an eligible beneficiary
  • OASIS data has been collected and submitted.
  • The agency is certified by Medicare.

Most patients meet the homebound criteria but many patients do not have homebound criteria documented well enough to warrant payment.  In case you missed it, here is a post about how to document homebound status.   

The patient is under the care of a physician should be obvious, right?  Not so fast, grasshoppers.  Not just any physician counts.  It has to be one that is licensed in your state or your state must allow physicians from nearby counties in another state to write orders.  Each state is different so read your physician practice acts and call the board of medicine if you still aren’t clear. 

The way that Medicare determines that a patient is under the care of a physician is by looking at signatures.   For years, we were told that if the physician failed to date his or her signature, we could simply enter the date the signed plan of care was received by the agency.  They changed their minds on that one a few years ago but not everyone got the memo, apparently.  Everyone in the agency who sees plans of care on a regular basis should be taught to look for dated signatures.  The earlier you find an undated signature, the more likely the physician will be able to sign an attestation statement with confidence.

Recurring, intermittent services sounds like someone is trying to confuse you.  In short, you may not see a patient indefinitely and you may not arrange to see a patient only once.

Daily nursing visits must have a written ‘end in sight’ to daily skilled nursing care included in the documentation.  The single exception to this rule is daily visits for insulin injections.   You can document this anywhere but I like to see it under the frequency or in the goals section.  Similarly, you may not plan to visit a patient once.  Physicians may call and ask for you to go to the house to remove sutures or administer a flu vaccine.  These visits would not be covered under the Medicare home care benefit although you can give a flu shot.  If a patient dies, moves out of town or refuses services after the admission visit, you may bill for it because you fully expected to see the patient again.

I think we have covered, recovered and stripped bare the Face-to-Face documentation requirements in prior posts.  If you continue to have questions, read here

Skilled care is defined in the Medicare Benefits Manual, chapter 7.   I always have a copy on my iPad and my desktop but whenever I can, I go to the online version because changes are fairly frequent.  You can identify the changes by the red font.

Everyone checks eligibility right?  I seldom see a problem with that but when one occurs, it occurs in a very big way.  Usually, an unfortunate soul without Medicare or insurance will borrow someone else’s card.  Although you are completely clueless, it is still non-billable.  That means you have to give the money back.  If you find out about it before Medicare does, you have 60 days before the money is considered fraudulent (that applies to all overpayments).  Whenever possible, check identification on admission.

It seems that until recently, agencies sent OASIS data in one direction and claims in another and the two never met up and the penalty for not submitting OASIS data was very scarcely enforced.  At some point, the OIG got wind of this and jumped all over Medicare in a long and boring report last year.  Now now you will be denied on an ADR if the OASIS data has not been submitted. 

I think you will know if ever your agency becomes decertified so let’s just skip that one.  (Hint:  one big clue is the lack of payment.)

Your state surveyors do not know much at all about billing.  The Face-to-Face requirement is not a requirement for licensure.  In all likelihood, you probably know more about OASIS and coding than a surveyor does because they do not do it every day.  The state really doesn’t survey your length of stay.  The state wants to know if you meet the basic requirements to provide care for patients.  If you are still confused, consider that the state employees are paid by state taxes to protect the citizens of the state.  Medicare pays contractors to protect the trust funds (large piles of money) used to pay for the care.

If you have a perfect survey, it means that you are doing many things right.  In fact, if you get in trouble with your state agency, there will come a point in time where they will communicate with Medicare and your provider number will be at risk.  I’ve only seen that happen a few times by people who do not read stuff like this. 

Now think about all the reasons agencies have claims denied.  They are not included in your state survey.  And that is how you can have a perfect survey and still get denials or worse. 

Now you know. 

Questions and comments are always welcome.

Compliance is Good Business


In my experience, the greatest barrier to compliance is that it costs money to be compliant.   Compliance plans are cheap compared to turning away referrals that competitors eat up like candy.  Discharging patients when you think you could maybe squeeze one more episode out of them is hard for some people to do.  Marketers working to develop a new referral source are horrified when an admitting nurse turns down a referral because she doesn’t believe they meet Medicare criteria.  There is no doubt about it.  Compliance costs money.

The real question in business is whether or not your investment will show a return.  We all know the businesses who spend far too much money, those that are conservative with their cash and some that are just plain cheap.  The cheap ones will never get it. If you are cheap, you can head on over to Ebay and buy some second hand computers and forget about the rest of this post.  Those that spend far too much money might have already found themselves in a position where their entire operation depends on making use of the gray area which is getting smaller by the minute.  The providers I am talking to are the ones in the middle.  It is hard to get a good provider who has no compliance problems to buy into implementing a compliance plan.  What’s the point?

Here’s the point.

Every day, you sell nursing care and therapy to physicians and other referral sources.  You charge the same amount as your competitor and you cannot offer any discounts, specials or coupons.  You even sell to the same ultimate buyer – Medicare.  You tell the referral source that your agency is the best in the market and that you are trying new and innovative things to keep patients out of the hospital.  You share a donut or a brownie, perhaps and ask about those Cubs even though you hate baseball because you know the referral source loves the Cubs.

Five minutes after you leave, in walks your competitor who says the exact same thing.

Nobody says, ‘Yeah, well we offer mediocre care but we’re no worse than anyone else.’  Even when it’s true nobody says, ‘we suck at what we do but we offer more cash under the table.’  If it really isn’t your day, the doc has a new flat screen delivered to his house or the discharge planner finds a few loose diamonds in the pocket of her scrub jacket after they talk with your competitor.

So, what’s the point of marketing compliance?

Read carefully.  This is important.

You Do Not Sell What You Do.  You Sell Who You Are. 

Is that clear?  The entire healthcare industry has been under what feels like an attack for the past three or so years.  People are running scared.  The FBI is out and about in a big way in the south.  Three physicians in New Orleans involved with a home health agency were raided a couple of weeks ago.  Regardless of the outcome of the FBI raid, no referral source will work with the agency or any of it’s owners/managers again.

Let the FBI be part of your marketing team since they seem to have no desire to go away.  They are not conducting training exercises and there will be casualties.   Work it!

When legitimate referral sources hear about their colleagues getting raided, it does not mean they will no longer have legitimate referrals for ethical home care agencies and hospices.   You need to be ready for their referrals because the providers who are known for their integrity and ethics will be the first ones called.  They are going to choose the one who never breaks the rules, can speak intelligently about the regulations and provide them with substantiated guidance assuring them that what you are asking them to sign meets all known rules and regulations.

Consider the referral you turn away because the patient doesn’t meet hospice guidelines.  Sure your competitor will take it but when you get the chance to explain why you made the decision, a message is delivered that your competitor was operating in reckless disregard of the regulations or maybe just stupidity.  There won’t be too many of those referrals in the future as more docs are having their lives turned upside down because of a relationship with a less than ethical provider.

A compliance plan has other benefits, too.  A soundly implemented compliance plan can distance you from any wrongdoing by a rogue employee.  In other words, if a new hire doesn’t make visits and hands in notes anyway, you can find yourself in a costly situation of returning money to Medicare or you can find yourself arrested.  The deciding factor will be if the employee was working in a culture where effort was made to verify the integrity of the work submitted vs a finding that a rogue employee was part of a culture of fraud.  Ignorance is not an excuse, y’all.  You have an obligation to look for compliance issues.

Compliance Plans

We regularly work with providers who want to establish a culture of compliance.  I find that if the FBI arrives before I do, the motivation is there to do the right thing.  If a compliance plan is just a binder in the corner that looks impressive and compliance training is given with a wink wink nod nod attitude, it is worse than useless.  It can cause more harm to the provider because a reasonable expectation that their employees know how to be compliant has been established and there were no internal audits to identify areas of non-compliance.

We don’t want to work with you if you think implementing compliance looks good in the likely event that you will have company soon.  On the other hand, if you believe like we do that compliance is good business, we can help you.  We feel so strongly about compliance that I’m willing to tell you that a half baked, ugly as home-made compliance plan implemented with full hearted commitment is better than the most expensive and complicated plan ever created that sits on a shelf.

You do not sell what you do.  You sell who you are.

Be the provider that referral sources trust and respect.

Confined to the Home


Here’s the point of this entire post.  Medicare knows the definition of ‘homebound’.   Medicare states that patients don’t have to be bedridden but there must exist a normal inability to leave the home and that when the patient does leave the home it requires a taxing effort.

As it turns out, most of us and quite a few physicians also know the definition and write it verbatim on visit notes, care plans and face-to-face documents.  When Medicare documentation calls for ‘reason homebound’, they are not asking for their own definition.

So, here’s my way of avoiding those pesky denials related to homebound status and overturning the ones that do get denied.  At the time of admission or recertification document all of the reasons why the patient can’t just up and go and all contributing factors.

These are very incomplete lists but I always try to support homebound status with as many factors as are applicable to the patient.

Absolutes Supporting Reasons
Severe pain with ambulation multiple medications that can impair balance
Safety concerns due to recent hx of multiple falls. multiple meds that can impair judgment
Disoriented to person and place and must be supervised at all times urinary incontinence
Short of breath while talking, eating or repositioning in bed cumbersome assist devices
SaO2 drops to 87 with activity apprehension about leaving home
Unable to ambulate safely s/p hip replacement moderate pain after standing for extended periods
Impaired judgment secondary to psychiatric illness cannot open some doors, drive or use left arm to balance due to splint
High risk of infection due to open wound and compromised immune system. requires considerable effort communicate needs clearly due to residual aphasia and paralysis of dominant hand.

 

Note the difference between the Absolutes and Supporting reasons.  People are not considered confined to the home because of apprehension alone but it adds depth to a complete picture of a patient with severe pain when ambulating.

Patients short of breath while talking or eating who are also incontinent and rely upon an assist device to get to the restroom are at very high risk for falls.

Documenting all assessment findings that contribute to homebound status at least once an episode and then continuing to support these reasons in your visit notes may very well get you paid.

486 Summary Example:  Patient homebound due to hip replacement two weeks ago and cannot walk without another person assisting him with his walker.  He is taking narcotic pain medications which increases his risk for falls and there are steps without a bannister leading to the front door.

The truth is that we all meet Medicare’s definition of homebound status at times.  Isn’t it hard for you to leave the house in the morning?  Surely it is a taxing effort for you to make sure all the kids have their lunch and homework, find your keys, retrieve your cell phone from the litter box where the toddler put it and somehow make it to the car.  If a normal inability does not include four trips to the car and back to house to retrieve forgotten items including the baby, then crazy is the new normal.

Medicare doesn’t care about any of that. They want to know, from a clinical perspective, how the patients meet the criteria they set forth for us in the conditions of participation.  We need to paint a crystal clear picture and not just write enough to meet guidelines.  When you are finished documenting homebound status, there should be no question that the patient cannot and does not leave the home.

If there is a question, go take a second look.  If you cannot elaborate on ‘SOB with exertion’ (as I am after climbing 6 flights of stairs), your patient may very well not be homebound.

Of all the wild excuses for denials lately, this one is not so unreasonable.  We can do this without changing the law, involving physicians, and praying that the grammar police don’t get us.

Good luck.  I am very confident we can take this denial off the table.

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