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Posts tagged ‘Focused Medical Review’

Writing a Corrective Action Plan

Many providers who have been on a length of stay edit have just received an invitation from their MAC to write a corrective action plan. This is a good skill to have if you take it seriously and actually use it. The required components are pretty much the same as any plan of correction for a state survey or quality assurance plan and if you take the time to do it right, you will have a spare brain when things get hectic. The problem, as I see it is the order in which the components are presented on a typical corrective action form provided by your state agency or Medicare contractor. They are usually presented as such:

  1. Problem (I like to euphemistically call this ‘Opportunity for Improvement’)
  2. Intervention
  3. Expected Outcome (goal)
  4. Responsible parties
  5. Method of evaluation
  6. Expected date

So, why don’t some plans stand a snowball’s chance in the Sahara of succeeding? The order in which they are listed often dictates the order of plan development. Let’s try something new.

  1. Area noted for improvement: This one stays in front but be careful. The surveyor may not know what your real problem is.

    Example: A surveyor noted that 4 out of 6 charts with lab did not have the results on the chart. What the surveyor missed was two charts that were not pulled where a patient wasn’t seen for two weeks because of a scheduling flaw or the three phone calls from patients asking where their nurse was. These problems are likely related and have more to do with scheduling than lab. You are not obligated to call the surveyor or your Medicare contractor and tell them that the problem is much larger than they imagined but if you want to be effective, address scheduling. It could be that schedules are left to the field staff with little or no oversight, the schedule is not adhered to, nurses are changing their schedules without notifying anyone, etc. These are the issues that must be addressed as opposed to say, filing lab.

  2. Responsible Party: First of all, no matter what the task at hand is, the responsibility always defaults to one of two people; The Director of Nursing or The Agency Administrator. The actual person performing the task will often dictate how the task is to be done. Most of the time, it is apparent who will be responsible for the task. If the problem is billing without the appropriate OASIS assessment having been complete, the choice of responsible parties has been narrowed to a couple of people in the agency. Is the biller not performing a check? Who is reading the validation reports? Does the person currently responsible have the time for it? Is there a backup for the OASIS Submitter? Should there be one?

    If you really want your plan to work, have the people who will be doing the work participate in the development.

  3. Expected Date: The expected date will influence the goal and the intervention (next). For an agency quality assurance program, a 90 day goal to get 90 percent of patients weighed might be reasonable. For a state survey and payment audits, you have considerably less time. Often, the best solution takes longest so sometimes a compromise is in order.

    A note about state surveys: It is rare that follow-up surveys are made these days due to budget restraints but if your agency is expecting a repeat survey, your date of completion should be the very last day possible. The reason is that the surveyors will come before day 45 to be in compliance with Medicare regulations and they will only check the charts for the specific deficiencies that occur after the date the agency said they would be complete. This not only limits the documentation that is reviewed by the state but it allows more time for a new process to be integrated in an agency.

  4. Goals: In the wake of a survey, your goals are pretty cut and dry but you must make them realistic. There are no perfect agencies. By allowing a certain margin of error in some areas, the agency can set very high standards which will result in agency wide priorities in other areas. Again, each agency knows the weak links. Are missed visits really missed or is the paperwork incomplete? Personally, I am okay with missed visit documentation being present only 85% of the time. I can live with a nurse’s failure to call the MD for a blood glucose of 201 when the upper parameter is 200. Where patients really get into trouble is when medications are overlooked, given by mistake, taught incorrectly or not assessed at all. My opinion is that medication teaching and assessment needs to be a high bar set at 100 percent. So, figure out what can be done, if what can be done is enough and somehow set a reasonable bar as high as it needs to be.


  5. Interventions and Evaluation: If you consider how you will evaluate an intervention as you are determining what action should be taken, it will result in a more complete plan likely to succeed. Consider a probe edit where multiple claims were denied because there was no evidence of skilled services found in the clinical records upon review. When you considered who would perform the tasks involved in correction, you identified the nurses and therapists with ultimate authority defaulting to the Director of Nursing. Because this is a probe edit that could jeopardize your agency, your deadline is tighter than ideal; thirty days. Now all that’s left is to determine what should be done.

    Nine times out of ten, the designated activity includes ‘inservice all staff on skilled services’. How nice. You have a dozen or so nurses out there who are unaware of what a skilled service is. How about that? By all means, re-teach what constitutes a skilled service but if you stop there you will be disappointed in the results.

    If you do reteach your staff, how will you evaluate? I have taught inservices where all the staff played with their cell phones and I have held inservices where the staff participated to the extent that it seemed more like a panel discussion with everyone participating. I like those. Regardless, an attendance sheet isn’t nearly as good as a test. If a certain grade is required, the evaluation is easy. It would look like this on a Corrective Action Plan:

POCWe are always willing and able to assist in your corrective action plan but go back to number 2 – the responsible parties. We can always write something pretty that will be accepted but the agency must implement the plan. The chances of a successful implementation are far greater if the agency employees have bought into the plan. If you do not have solid support for the plan, the next best thing is to evaluate your retirement plans because the agency will fail unless major shifts in culture are made.

Dance Lessons

If hell is spelled Z-P-I-C, then purgatory is spelled ADR.  If you have been in home care for a long time, you know all about the old FMR process.  If you are new to home health, imagine every word you write being scrutinized by someone who wants nothing more than to find that your work is unacceptable and substandard so they don’t have to pay your employer for it.  It’s rather uncomfortable.

One of the comments I hear regularly from nurses is that they are not worried about ADR’s or even ZPICs because they have done very well on recent surveys.  There are important distinctions between licensing and certification standards so it is entirely possible to have a spotless survey and still have your Medicare dollars at risk.  It happens every day.

The recent onslaught of ADR’s is very much like the Focused Medical Reviews in the past but with a few significant changes.  So whether you have been around for a while, there are some interesting twists to this new trend.

The most significant change is that agencies are now being told why they are being chosen.  There are no secrets.  This tiny but remarkable change now means that from the beginning of the audit process, agencies who want to do well can do well.

A ‘probe edit’ starts when your data is significantly different from your peers, usually resulting in more payment to the agency.  Here are some of the more important things you should know if your agency begins to receive multiple ADR’s.

  1. The Medical Review Department of your MAC (FI) requests a total of 20 – 40 episodes that meet the criteria for the edit that has been attached to the agency. 
  2. There is no time limit for the ADR’s to be sent to the agency.  It is dependent upon agency billing practices, Medicare census, etc.
  3. A letter will be sent to the agency for each claim that is under review. 
  4. You have 30 days to send the records to the FI.
  5. This information is also available through the DDE (billing) system and I strongly recommend that you rely on DDE as opposed to the mail.
  7. Once all of the letters have been sent, the ADR’s stop.  The edit is put on hold until your claims have been reviewed.
  8. Do not mistake this lull in activity as an indication that the MAC (FI) is through with you.
  9. The FI has 60 days to review the clinical records and make a determination about your agency.
  10. This determination may be made after only 20 records have been reviewed. (This puzzled me but if you are really, really good or really, really bad, the math works.)
  11. If 77% of your claims are found to meet payment standards, you are usually taken off the radar unless a seriously egregious error suggestive of willful and blatant fraud is discovered. 
  12. If you have a higher denial rate, the dance continues for another round.
  13. Education is provided by the MAC or FI during this time.  It usually consists of memos cut and pasted from the Medicare Benefits manual. 
  14. Whether or not you continue Waltzing with the MAC or get down and dirty with a Zone Contractor who has the ability to take you from purgatory to hell depends on how well you dance. 

So, may I suggest dance lessons?  If you already know how to dance, then at least make it a point to send in the requested documentation timely.  If you go for a second round with a major denial rate (67%), you will find out why Hell is spelled with a Z or worse.

Call us or email us for any questions or assistance with ADR’s.  You cannot do anything about being placed on an edit but you can make sure it stops after only one dance.

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