Skip to content

Posts tagged ‘fraud and abuse’

A New Push for Hospice Reform

A new focus on Hospice Fraud stemming from reporting by Propublica and The New Yorker.

Read more


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


Priscilla Demonstrating a Proper Face-to-Face Encounter.  She continues to work on documentation skills.

Priscilla Demonstrating a Proper Face-to-Face Encounter. She continues to work on documentation skills.

I have never been a big fan of associations and organizations.  I am not a joiner in general.  Specifically, I have been very frank about my feelings towards the National Association of Home Care and Hospice.  I believe that in the past they took on causes that benefited some agencies at the expense of others.  In many ways, it is almost impossible to be an organization representative of all agencies of all sizes in all parts of the country.

As of June 5, that changed.  William A. Dombi, attorney for the plaintiff – your association – has filed suit against the US Department of Health and Human Services.  NACH is challenging the requirements regarding documentation of the Face-to-Face encounter.  They allege that Medicare is enforcing the Face to Face encounter requirements in ways that were never intended and are not legal.  They note that these retroactive denials are made outside of the consideration of the care needed by the patient or the quality of the care rendered to the patient.

This is good stuff, y’all.

Because I was so outspoken and passionately against the position NAHC took in the past regarding other issues, I owe it to the Association (and to myself) to be as outspoken and passionate in my support of this lawsuit.

If NAHC asks anything of its members, please cooperate to the best of your ability.  If nothing else, send the board at NAHC responsible for approving the filing of the claim a note of gratitude.  This is one position that NAHC has taken that benefits all agencies, patients, and the Medicare trusts.

I can respect that.

Getting Paid Under Scrutiny

In between hurricanes and frightful traffic, I have been fighting for money that other people want to take away from my clients.  My first intention was to show  you the language typically used in the denials I have been seeing from the Zone and the MACs.  Then it occurred to me to show you what was written when the claims were allowed.  This might be of greater value.

Medicare guidelines for reimbursement have been met. Patient received physical therapy services due to recent fall and weakness. Skilled nursing services for medication changes and observation and assessment of disease process. Therefore, it is allowed.

Medicare guidelines for reimbursement have been met. The patient required medication changes related to her hypertension and hyperkalemia. Therefore, the episode is allowed.

Medicare guidelines for reimbursement have been met. The patient had multiple medication changes related to blood pressure fluctuations that required monitoring. The skilled nursing services are approved.

Skilled nurse visits allowed due to patient requiring skilled nursing assessment and observation. Pt had upper respiratory symptoms and was started on prednisone and phenergan expectorant cough syrup. Documentation meets Medicare criteria for reimbursement.

There were plenty other claims paid.  Some were paid because the patient went into the hospital for heart failure of renal disease.  I did not use those as an example because it is not sound clinical practice to induce an exacerbation for payment purposes.

The difference between these claims which have been allowed and those which are denied begins with the nurse in the home.  Three things must happen in order to rightfully claim that an exacerbation has occurred.

  1. The patient’s condition must change.
  2. The nurse must communicate the changes to the MD
  3. The plan of care must change as a result of the changes

The nurses whose documentation resulted in payment above did not get a blood pressure of 160/95 and write it off to the fact that the patient just walked down the driveway to get his mail and ignore it.   They don’t just assume that everyone has allergies this time of year and make a note to check on the patient again next week.  These nurses may be very friendly but they do not make visits that only social in nature.  They take the time to communicate changes, get orders and document.

More important than surveys and payment is that this careful attention to patients results in better care.

The parameters that are not mandated but are shown to be good practice when writing care plans can be an invaluable tool.  Everything else aside, if your patient exceeds parameters by only a fraction and you do not call the MD, you have not followed orders and that results in a survey deficiency.

When you communicate with the physician, have all the information required.  What has the blood pressure been over the past several weeks?  Is there anything else going on with the patient?  Were there any med changes?

Here is a visit note written in a claim that was denied.

take meds as directed

I am horrified that one of my peers actually accepted money from her employer for this level of nursing.  It does not require the skills of a licensed nurse to tell the patient to take meds exactly as prescribed.

Agencies can implement all kinds of strategies, hire the best consultants (if we’re available), set arbitrary visit rates and lengths of stay but unless the nurses visiting the patient take the time to really take care of the patient, it is all for naught.

But if you have good nurses, we can and will see you through a little regulatory scrutiny.

Be sure to drop me an email if you are getting any strange ADRs.  I am particularly interested in those with a reason code of 5Z5NP.

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.