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Posts tagged ‘documentation’

Nov 16

A Memorable Comment

Two years ago, I posted about Beverly Cooper who was convicted of multiple counts of fraud and was facing up to a ten-year sentence in Federal Prison.  See Press Release.   She admitted to signing visit notes when unlicensed personnel made the visits giving the impression that she made the visits; among other things – lots of other things.  Signing off on a visit that was made by someone without a license could have easily proved deadly to a patient.  Maybe Ms. Cooper is lucky that she didn’t kill someone.

Today, I received a message from someone, apparently a friend of Ms. Cooper’s pointing out that nowhere in the indictment (or my blog post) was Ms. Cooper’s 15-hour work days or dying relative noted.  The writer asked if I knew how wonderful Beverly Cooper was and pointed out that everybody makes mistakes.

Frankly, it would not surprise me if Ms. Cooper was a good hearted, likable woman.  Unlike less sophisticated crime, fraud on this scale is usually committed by people who are genuinely likable.

The writer of the message mentioned other people involved in the indictment.  She wanted to know why I didn’t mention them as well.  Frankly, they were not included in the press release.  Furthermore, Ms. Cooper was a Registered Nurse.   This blog is all about nursing and nurses and those who occupy our worlds.  That’s why Ms. Cooper made the blog post list.

I don’t know the person who wrote me the email and I never have met Ms. Cooper before.  I was nowhere near Detroit where all of this took place.  I cannot begin to speculate on what might have happened.  But, I can make reasonable assumptions based upon the criminal cases I have worked with and some former clients.

  1. Cooper was likely tired and emotionally fragile based upon what the writer said. Masterminds of fraud are incredibly smooth at exploiting the weaknesses of others.  She likely was not the mastermind.
  2. My bet is that Ms. Cooper was paid far more than an RN in a similar position. Should someone offer you twice as much as you are making now, be aware.  You are not worth that much.
  3. Cooper may have convinced herself or have been convinced that ‘everyone does it’. Wrongo.
  4. There may be somebody in the mix who could be legitimately diagnosed as a sociopath. Being without a conscience is mission critical to projecting the confidence required to persuade accomplices to achieve your purposes.
  5. I would bet the farm that at some point long before her arrest, Cooper figured out that she was committing fraud and had to make a decision. It could have been loyalty to her employer, a need for money, fear of extortion or just greed that convinced her to stay.  Sometimes, folks are too overwhelmed to think about a major life change.
  6. If this case was even remotely similar to other cases, the agency was investigated for years prior to an arrest. Beverly Cooper and her co-conspirators may have become complacent since there was so much time between the investigation and the arrest.

Let me reiterate that I do not know anything about these people.  They are not the usual fraudsters in Louisiana where we have enough home grown fraud that I don’t have to go looking in places like Detroit.  I have met many others who have faced a similar circumstance; enough to make assumptions.  I have enjoyed their company and worked hard for them and their lawyers and I took their money for my services.  But, when a clear pattern of fraud exists, there is nothing that I can do.  Criminal attorneys are brought to their knees trying to find a defense for their clients when there is none.   These are not thuggish criminals.  They are well dressed, well spoken professionals who say and do all the right things.

Your task if you are reading this is to know what a compliant agency looks like so you can find one to work with or create one to attract the kind of talent that you need to bring your agency to the next level.

The compliant agency:

  • Makes a lot of mistakes – it may seem like even more because they talk about mistakes, bring them out in the open and find ways to avoid repeat mistakes.
  • Has a lot of information scattered around the office about a code of conduct, employee hotlines and compliance committees.
  • Welcomes questions as a door for teaching.
  • Makes sure that employees have an anonymous way to report fraud.
  • Takes reports of fraud offered in good faith seriously.
  • Provides far more education in fraud than anyone wants.
  • Looks at processes and doesn’t blame employees for mistakes that involve multiple people and departments. There’s plenty of time to blame others if it happens again.  Fix it and move on.

Mistakes are costly to be sure but not nearly so much as hiding mistakes.  If you inadvertently make a mistake that affects billing and are fired after reporting it, smile on your way out of the door.  You don’t want to be there.  The agency has just sent a message to everyone else that they have a zero tolerance policy for mistakes and future mistakes will be hidden away.

Ms. Cooper may have been caught up in a storm she could not escape.  She may have discounted her actions as inconsequential or have been convinced she would never be caught.  She has lost her family, her marriage and her job according to the person who emailed me today.  She is completely without dignity.  On top of all of that, she is facing jail time.

I can’t help but feel compassion for her but more importantly, I am bound and determined to give all of you who take the time out of your day to read my blog the information you need to avoid a similar fate.  Unemployment is not half as bad as jail.

Jun 24

2 Comments

End in Sight for Home Health Services

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

Read more

Sep 30

3 Comments

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.

Sep 16

10 Comments

Face to Face Documentation Guidance

I have received several denials on face to face documents because the signature was not dated.  Would somebody please tell Palmetto GBA to lighten up a minute and read the regulations?   I would do it myself but I am busy trying to get y’all paid.

The Benefit Integrity Manual Section 3.3.2.4 reads as follows:

For medical review purposes, if the relevant regulation, NCD, LCD and other CMS manuals are silent on whether the signature must be dated, the MACs, CERT and ZPICs shall ensure that the documentation contains enough information for the reviewer to determine the date on which the service was performed/ ordered.

If you read carefully the actual face-to-face guidance, it is, in fact, silent on the whether the signature must be dated.  Here is what I cut and pasted from the Benefit manual. 

The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen 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 a signed addendum to the certification. It may be written or typed.

It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.

It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

Not only is the regulation silent about dating the signature on the face-to-face document, it references the signed and dated certification which for most agencies is the 485.  I am unable to infer that the regulations imply that the signature on the face-to-face document must be dated because it is illogical for the guidance to reference one mandated date and not the other. 

Does anyone disagree with me?  If the face-to-face document is sent after the 485, it would be difficult to prove that it was received prior to billing if it was not dated.  That is not my problem.  My problem lies in trying to figure out why Palmetto is playing so dirty with providers and working around their attitude to get my clients paid.

Let’s move on, shall we?  If they can play dirty, so can I.  Louisiana is home to swamps and New Orleans.  I know dirty.

The following are some examples of what Palmetto GBA considers to be inadequate documentation.

  • Diagnosis alone, such as osteoarthritis
  • Recent procedures alone, such as total knee replacement
  • Recent injuries alone, such as hip fracture
  • Statement, ‘taxing effort to leave home’ without specific clinical findings to indicate what makes the beneficiary homebound
  • ‘Gait abnormality’ without specific clinical findings
  • ‘Weakness’ without specific clinical findings

In the first three bullets, note the word, ‘alone’.  I wholeheartedly concur with them.  But, what if the diagnosis is accompanied by the procedure and the injury.  Suddenly, they are not alone.

The Medicare Benefit Manual defines homebound status for us as such:

An individual does not have to be bedridden to be considered confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.

I am fairly certain many of you have read that before.  If the definition suits Medicare, why is Palmetto above accepting it.  I understand that I can cut and paste those words anywhere.  If I saw a face-to-face with a single diagnosis of hypertension and the Medicare language for homebound, I would think twice about the validity of the document but that’s not what is happening.

I just finished with an appeal for a patient who was admitted post discharge from the hospital for pneumonia, sepsis, COPD and CHF.  The physician wrote that it was a taxing effort for this 85 year old to leave the home.  Well, I guess so.  Evidently, Palmetto GBA needs more information to arrive at the same conclusion.

Would a reviewer who could not understand why a patient with Sepsis, pneumonia, COPD and CHF would be short of breath, could they possibly distinguish between the eight different types of gait abnormalities related to neurologic conditions alone.   See 5th bullet.  (hemiplegic, spastic diplegic, neuropathic, myopathic, Parkinsonian, choreiform, ataxic (cerebellar) and sensory.)

Weakness – last bullet – is a good reason to stay home.  I don’t see the issue here.  Obviously, there should be something wrong with the patient that causes weakness but what specific clinical findings go with weakness?  “Patient was unable to complete ten reps with 20 pound bar?”

If I wrote a face to face, I would put something like:

Ms. Jane Deaux was seen by me on September 16, 2013 on the last day of her hospitalization for sepsis, pneumonia, COPD and CHF.  She spent 9 days in the ICU in a condition that is generally considered to be incompatible with life.   Without any regard to the rising cost of health care, the old woman refused to die.

She continues to complain about being short of breath and tired and refuses to accept that this is part of the aging process.    She has also called the office complaining of falls.  Reluctantly, I ordered physical therapy even though it is an expensive treatment modality for someone who might very well end up dying in less than a year.

She is confined to the home because she cannot breath very well when ambulating and getting to her car requires her to walk a short distance.  This ‘shortness of breath’ is caused by the inability oxygen to cross the alveolar membranes in the lung tissue resulting in a very low partial pressure of oxygen in her arterial blood.  The low PO2 manifests itself in a bluish cyanotic pallor which causes the patient to be self conscious as it draws unwanted attention from strangers.  Because carbon dioxide is not blown off in normal respiratory effort, her pH decreases causing her to become acidotic which leads to extreme electrolyte imbalances resulting in cardiac dysrhythmias expressed outwardly by symptoms of lightheadedness, falling, loss of consciousness, broken bones on impact and death.  As such I certify that it requires a considerable and taxing effort for this patient to leave the home.

I dare you.  I double dare you.  Find a doc and let him use this as a template.  Have the physician edit to fit the patient and see if it gets paid.  Just sayin…

Feb 10

5 Comments

The Checkbox Patient

You say the pain feels like an elephant sitting on your chest? I'm sorry but that's not an option. Let's move on.

You say the pain feels like an elephant sitting on your chest? I’m sorry but that’s not an option. Let’s move on.

I get frustrated when I see people try to squeeze an entire person into a series of checkboxes.  This has gotten under my skin for a long time.  Apparently, Medicare agrees with me.  Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.

The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time.  I provided the bold text.

The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.

The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.

CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.

Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.

Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.

If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.

So, be wary of programs that do too much for the nurses.  If a program doesn’t require at least a short narrative, it likely will not get done.  If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.

Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information.  You need reports and communication.  You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.

You do not need any more denials.  I assure you.

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