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Posts tagged ‘Haydel Consulting Services. homehealth nursing. ADRs’

Your Rights as a Provider

It is not my desire to create drama but then again, I am not the one who took away your rights as a provider.

Your contract with Medicare is simple.  It states that you are qualified to perform services for home health and hospice patients and Medicare will pay you according to an agreed schedule.  Occasionally, they review clinical records and refuse to pay based on their assessment of your chart.  If you agree with their decision as is sometimes appropriate, so be it.  If you feel as though you disagree with their decision, you can appeal.

Sort of…..

Last week, I heard a rumor started by the National Association of Home Care and Hospice that the ALJ’s weren’t going to be docketing any more cases from home health and hospice providers.  I knew this could not be the case so I emailed Mr. Dombi at NAHC and he responded by sending a scanned copy of a letter from the Chief Administrative Law Judge, Nancy Griswold confirming this complete and utter lunacy.

For those of you who do not work in the world of appeals and do more important things like take care of sick people in their homes, let me explain this to you.

Imagine you did something else for a living.  Humour me and pretend that you are a roofer.  My insurance company who supplies 95 percent of your business  agreed to pay you to put a roof on my house and you did a fine job.   You shingled my home with materials that will withstand a category 5 hurricane and then you sent a bill and my insurance company politely declined to pay it.   Since the services were covered under your contract, the advance Roof Recipient Notice won’t protect you and I am held harmless while enjoying the sound of the rain on my new Cat 5 roof.

You take your complaint to the board of insurance and they tell you that you are right!  You did install at Cat 5 roof on my house but it doesn’t matter.  No payment is forthcoming.  Their reasoning is that in order to begin work, they had you sign a 30 page contract and on page 27, halfway down, it said that in order to be paid, you must initial the bottom of every page of the contract.  You only initialed 15 pages.

You decide the whole world of roofers and contractors has gone crazy and decide to take the insurance company to court.  The problem is there is no judge to hear your case.

So, I get the roof.  You get nothing and you have no rights.  The insurance company who signed a contract agreeing to pay you is sitting pretty with another satisfied customer under a Cat 5 roof and all you can do is work harder and faster to make up for the lost dollars.

That is exactly what is happening with Medicare appeals right now.  Payment is being refused for up to half of all claims at some MACs (e.g. Palmetto GBA, NGS, CGS) and you do not have any right to appeal denials past a certain point.  There is no person that you can talk to and you are completely unsure if anyone is actually looking at your records before rubber stamping  ‘denied’ on your claim. In short, they don’t give a flying flip that you had to pay your nurses or cover supplies.

When I work appeals, most of my work is done with the ALJ in mind.  If it’s good enough for them, it should satisfy the lower levels of appeals but often it does not.  The ALJ is the first human being that you can plead with to be reasonable. Except in desperate and extreme cases, the appeals process ends there.

Ms. Griswold confidently speaks to the increase in the number of denials being appealed but she does not speak at all to the increase in denials that are fully appealable or the rate of denials being overturned by Administrative Law Judges for the first two levels of appeal.   If the first two levels of appeals were performed competently, the workload at the ALJ would naturally fall as a byproduct of efficient, ethical and fair clinical reviews.

She makes a very valid point that the number of cases has increased overwhelming the ALJ’s but instead of addressing the huge percentage of denials that should have never been, she asks for ‘indulgence’.  It’s like pouring salt into a wound.

How dare Ms. Griswold ask for indulgence when almost half of the claims for home health have been denied by some MACs for grammatical errors relating to the F2F encounter documentation?   She wants to thank us in advance even though she has the responsibility to be well aware that her staff is ultimately overwhelmed due to the enormous increase in unfair denials.

I beg for your indulgence when I say that someone in Washington, starting with Ms. Griswold needs to have the courage to stand up for the good providers and quit playing political games with the healthcare needs of our elderly.

According to the HHS website, Ms. Griswold can be reached at:

OMHA Headquarters
1700 N. Moore St., Suite 1800
Arlington, VA 22209

Phone: 703-235-0635;   Fax: 703-235-0700


Make use of this information.  If you don’t speak up now, you may not be able to later.

Thanks to NAHC for sharing this information freely without regard to membership status. The content and sentiment in this post are mine alone and should not be attributed to NAHC or any other entity or person. 

Skilled Charting

Our small little company probably sees more denials than anyone else other than say Palmetto or one of the Zone contractors.  So we make a lot of fuss about documentation and getting paid but while we are very good about finding errors, we don’t offer as much as we should in teaching documentation with payment in mind.  I’m not going to bother with that now as I have a lot to do so let me just show some examples of bad, better and really good documentation.

Skilled Teaching – Diet

Bad:  taught low sodium diet.  (worse if this is not the first time)

Better: Taught patient how to read food labels for sodium content.  Used handout attached.

Best: Taught American Heart guidelines for low sodium diet according to handout pages 1 and 2.  Copy attached and left in home folder.

Homebound Status

Bad:  SOB on exertion (everyone gets short winded if they exert themselves enough)

Better:  Patient is short of breath when walking 20 feet.

Best:  Patient is unable to leave the home due to SOB r/t CHF, arthritic pain and impaired judgment due to narcotic medications.  Requires cumbersome assist devices and at least one person to help leave the home.

Diabetes Foot Check

Bad:  Taught patient to perform foot care.

Better:  Inspected all surfaces of feet.  No problems noted.  Patient was able to demonstrate foot care with a mirror.

Best:  Inspected all surfaces of feet while simultaneously instructing patient on foot care and (proper footwear), (risks of decreased sensitivity), (risks of going without shoes), (when to see podiatrist), (importance of annual eye exam).  Take your pick and rotate through the list.


Bad:  PT/INR drawn per orders and brought to lab.

Better:  PT/INR drawn per orders.  Called team leader to watch for results.

Best:  10:00  PT/INR drawn.  Dosage of 5 mg/day Coumadin noted on lab slip.  4:00 pm  MD confirmed receipt of lab.  INR 2.8.  No new orders.

Any0ne else care to add to the list? Yes, you’ll chart a little more but if you blow off the recap of what is on the flow sheet – assessed all body systems, patient awake alert and oriented times 3, denies pain, etc., etc., you may find that you write less and say more. Better yet, you will get paid for your hard work and your outcomes will improve as well.

A Slap in the Face

So last week I was reviewing clinical records at the office of one of my favorite clients.  A patient had been admitted six months after having half of her foot removed.  She had not walked since the surgery and was confined to the bed and the chair.

The first thing I noticed was that the description of the surgical wound sounded as though it were partially granulated instead of fully granulated.  Six months is a long time but remember, amputations are not cosmetic surgery.  It would not be unheard of to have a wound slow to heal in someone with circulation impaired to the extent that part of a foot needed to be removed.

I also questioned the diagnosis sequence and a couple of the OASIS questions in the functional domain.

Med orders on the 485 indicated that the patient was on both Dilaudid an Lortab but the chart only mentioned Lortab as being used for pain.  My most humble opinion is that if pain is being managed with Lortab, the Dilaudid should come off the orders – especially after the first episode.  The reason I feel this way is because if the patient had a sudden need for stronger pain relief, she may have other needs than Dilaudid that should be addressed immediately.

She had both therapy and nursing ordered.  The nurse was quick to realize that the new orthopedic ‘boot’ designed to help her walk was causing the surgical wound to become red and irritated.  Both the nurse and the therapist addressed this with the MD and the people who made the boot.  I certainly cannot complain about that.  But, after the boot was refitted properly, the nurse stayed in the home weekly even though therapists should be able to assess wounds.

In summary, I saw was that OASIS scoring left the agency with less payment than they were ethically entitled to for a very expensive patient and services being provided that may not have been required.  And of course, there was the regulatory issue with duplicate pain meds.

While I was busy finding fault left and right, the most important thing almost escaped my attention.

After two episodes the patient who had part of their foot removed and had not walked in six months prior to admission was ambulating with a walker.  The last nursing note state that the patient was in the kitchen upon arrival making coffee and using her assist device.

I am still not happy with the chart.  My slap in the face comes from the fact that sometimes we forget that documentation is second to our real mission of providing care in the home.  It is a very close second but failure to acknowledge what these incredible nurses and therapists did for the patient is the kind of attitude that deserves a slap in the face.  If those of us who review charts on a regular basis cannot read between the lines and respect the care given to patients, we have no right to expect respect from field clinicians when we tell them all the things they did wrong.

Having said that, I have seen like a billion ADR’s and ZPIC denial letters but I have never seen one like the following.  Please forward to me if you have.

Dear Administrator:

After careful review, our Medical Review department has determined that the cases mix weight determined by your OASIS data is in error.  Specifically, a surgical wound and the functional domain were underscored resulting in a lower payment for this patient.  In light of these egregious errors, Palmetto GBA (ZONE contractor or MAC of your choice) is adjusting your claim to reflect the correct diagnosis, surgical wound and functional status of your patient.  This will affect the overall denial rate on your current edit.

As a provider, you have certain rights to appeal.  Please see attachments on how to appeal a Medicare decision regarding payment.


(Insert the name of your MAC or Zone Contractor)

PS  please advise your nurse to take Dilaudid off the current med list and ask the patient to place it in a Ziplock bag with a large note that tells the patient to please call the nurse immediately should it be required in the future.

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