Skip to content

Posts tagged ‘Haydel Consulting Services. homehealth nursing’

Hospice Meds and Medicare Part D


If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

The Best Christmas Present EVER!!!


Choosing the perfect Christmas present for a 13 year old girl can be a challenge.  One minute they want mascara and designer jeans and two hours later they want a new Barbie doll.  Ponies are always nice but not an option for most families and very difficult to wrap.   Still, most parents will go to the end of the earth and back to find that perfect gift for their daughters because they live for the shrieks of joy and overplayed excitement that consume a happy 13 year old girl.

Yesterday, one family arranged for their daughter the best Christmas present on the planet.  It is also the last present that they will ever give to their daughter and they will be without her on Christmas morning.  I don’t know anything else about this child or her family.  I wouldn’t have even known she existed until a friend updated her status on Facebook last night.

Liver.  Tonight.

My friend is married to the love of her life and has been watching him die a slow, lingering death of liver failure and knew that she would lose him if a transplant did not become available soon.

Three hours later:  ‘Surgery going well’.

Wanna know something funny?  I  have ever spent a lot of time with my friend except on Facebook and other social media.  And yet, somehow I wanted the liver to be perfect.  I have no dog in this race but I wanted a win more than anything.  This is not about me and somehow, it felt like it was.  All I know is that I was desperate for the liver to be a perfect fit.

Two hours pass.  ‘Surgery finished. New liver working wonderfully. Going to ICU now’.

Okay, I admit it.  I actually shed a tear or two but it was late and I don’t cry if anyone asks.  I was also a little confused and overwhelmed by how much someone else’s  liver transplant affected me.  That’s when I realized my FaceBook friend was wrong.  Nobody got a ‘new’ liver last night.  It was a slightly used model.

The used liver had the blood of a teenage girl coursing through it yesterday and for the last 13 years.  As plans are being made to lay her to rest, another family gets a fresh start.  Could anything be greater than a parent’s love for a child?  Could a parent love their child enough to set their grief aside for a minute to impart even more meaning the abbreviated life of their child?

You tell me.

A 13 year old girl received the gift of having the value of her short life multiplied countless times as her parents allowed her liver to go to another patient who has a family who loves him as much they love their daughter.

Earlier this morning:  He is slowly waking up

Merry Christmas, Baby.  Open your hearts and eyes and see that there is such a thing as boundless love and our gift from the parents of an anonymous donor is being awestruck if only for a minute by their infinite love for their daughter as she is laid to rest.

Please put a note on the thirteenth day of the next thirteen months to remember and honor this child and her parents.

Urgent Call to Action


The short title is the Medicare Fraud Reduction Act. This ‘act’ places caps on your aggregate number of episodes.  Representative Jim Matheson, a democrat from Utah introduced a bill into congress on October 4th, and Representative Brett Guthrie, a republican from Kentucky co-sponsored the bill.

H.R. 3245 of the 113th congress (you have to state the 113th congress or web results will show cocaine sentencing laws) as I understand it, states:

  1. No episode will be paid for after the agency meets its caps.
  2. The cap is 3.3 episodes for agencies that reside in a rural area
  3. The cap is 2.7 episodes for all the rest of you.
  4. When more than one agency sees a patient, the episode credit is divided proportionately between the agencies on a percentage of episodes basis.

If this looks familiar to you, it reads exactly like the proposal The Partnership for Quality Home Health (click to see members) submitted to Congress signed by Eric Berger.  Note the 4th paragraph of page four of the proposal.

And yet, both Eric Berger, CEO and paid lobbyist for The Partnership of Quality Home Healthcare, and Bill Dombi of NAHC deny having anything to do with this Bill.  Eric Berger pointed out that the language was available on the internet for anyone to use and apparently somebody did.

My first response was that one of them was being less than truthful but their denials were direct and to the point.  I do not believe that either man would commit to writing a falsehood.

You are obviously free to your own opinions about caps but I do not like this idea not one bit.  However, the best I can do is make sure you know about it so you can act on it in the manner in which you see fit.

In researching the so called recommended targets for fraud reduction, I found some interesting facts which I am certain have no bearing on the length of stay required by a patient.

  • In Bogalusa, Louisiana, 15 percent of residents have diabetes.  This is twice the rate of the rest of the country.
  • In East Carol Parish, a full 57 percent of children live in poverty which I assume is a fairly decent indicator of the overall economic status of the community.
  • Hancock county in Tennessee doesn’t report on drug use or alcohol use but they have more than triple the number of deaths from motor vehicle accidents.
  • Like the other hot spots, Hancock County has high unemployment (50% higher than the rest of the state) and very poor educational levels.
  • There are three counties in Mississippi that hit the target list.  Consider that in Mississippi taken as a whole, 32% of children grow up in poverty.  For the three fraudulent counties, the percentages are 46%, 52% and 53%.  If they are fraudulent, they aren’t very good at it.  Someone should be getting the money stolen from Medicare.
  • In one Mississippi county, a full 78 percent of people had water exceeding a violation in the past year.
  • Perhaps the most tragic is the violent crime in these three counties.  In Mississippi, 280 people out of every 100,000 is expected to become a victim of violent crime.  The county with poisonous water (Sharkey) has a very low rate of 72 incidents.  Jefferson County counted 443 victims per 100,000 but Claiborne county takes the prize with 770.
  • In Madison Parish, Louisiana, you have a one in ten chance of being a victim of violent crime which is a shame because it is one of my favorite places.  I had no idea I was in such danger.

Add it all together and you have a bill introduced to congress that will limit access to care to elderly people without resources.  Their families are stressed and stretched thin.  Neither the patients or their families have enough education or money to log on to a computer much less email their senator.  They are the men and women who didn’t need an education to farm our land and feed us for fifty years before they retired.

They are disproportionately African American and disproportionately elderly in the counties where they reside as the younger people who could leave have left.  For the most part they have outlived their usefulness and have no voice.   If we don’t speak up for them, who will?

Of course, I have gone way off track.  None of these tragic figures in any way contribute to longer lengths of stay.  Rather, the home health agencies commit fraud.

Most of my data was obtained from the County Road Maps.  It is a great site where you can find a plethora of information about your community and there is even grant money available if you can come up with a plan to address your data.

Its important that all of our voices are heard.  Even if you disagree with me, contact your state representative.  I am going to contact mine and I will also email and call Bill Matheson and Brett Guthrie every day for no other reason than I didn’t have any time off this weekend because of their ill advised nonsense.   If you click their names, you will be taken to their contact forms.

If for some reason you are inclined to like the proposed reform, I would like to hear from you so I could begin to understand who would think this was a good idea.

Comments welcome.

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.

Patients for Sale


I sound like a broken record reporting on fraudulent activity so often these days.  It really is not what I want the focus of this blog to be.  Normally I would not report on a fraud conviction related to a partial hospital program, sleep clinic, etc. but I think we all need to pay attention to why these people are going to jail.  From the HHS press release:

According to court documents, ATC’s principals paid kickbacks to owners and operators of assisted living facilities and halfway houses and to patient brokers in exchange for delivering ineligible patients to ATC and ASI.  In some cases, the patients received a portion of those kickbacks. 

What this means to you is that if you or your agency enter into any agreement where cash or goods are provided on a per referral basis, you may find yourself in jail.  My recommendation is that any arrangement where someone is paid a bonus for referrals be reviewed by a healthcare attorney.  If you choose to ignore my advice, please at least consider the following advice.

  1. When selling patients, charge a lot more than $50.00.  There are hidden costs in this line of work including legal fees and bail money.  Do NOT accept checks or credit card payments when selling patients.
  2. When buying patients, at least give them a token amount of health care.  I am petitioning God for a special kind of hell for those that bill on our most vulnerable members of society and don’t even give them much needed health care.
  3. If your generosity to patients includes flat screen televisions, cash, WalMart cards or rides to the physician’s office, have the patients sign a confidentiality agreement first.
  4. If you pay an outrageous amount of money for rent to another facility so you have access to their patients, make all payments in unmarked bills.
  5. If you market directly to patients, wear a disguise, drive an grey sedan and use a fake name.  Do your marketing before 8:00 am and after 5:00 pm.  The feds keep a pretty predictable schedule and you will be less likely to draw attention.  

Of course, the best way to market is to provide impeccable care and become known as the agency who keeps patients out of the hospital and goes further than other agencies to attend to patient needs.  It has come to my attention that some agencies are unwilling to go that route.  If you are one of them, heed my advice.  You will still be caught but you may have a little bit of cash stashed away for legal fees.

%d bloggers like this: