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Posts tagged ‘Home care’

Reducing Fraud

Everyone agrees that the industry has had enough of fraud.  In fact, some industry leaders have already declared, ‘Enough is enough!’.  I wholeheartedly concur with that eloquent and emotional pronouncement of the common values of Home Health Providers.  So lets take a look at how we can reduce fraud and cut the home health budget, shall we?

  1. Ensure that nobody gains entry into the Medicare program without undergoing a criminal history background check.
  2. Test all owners and managers according to standards set forth by The Secretary to ensure that all owners and managers understand HIPAA, coverage guidelines, compliance rules, marketing guidelines, etc.
  3. Require providers to put up a 100K surety bond and demonstrate they have the capital to operate.
  4. Mandate compliance programs or if you prefer, ‘Promulgate rules requiring home health agencies to have in operation a compliance and ethics program designed to prevent and detect criminal, civil, and administrative violations’.
  5. Do not issue provider numbers in geographical areas where there is a lot of fraud or where there are a lot of providers.
  6. Put a Cap on Episodes much like IPS.  Urban agencies will be limited to less than two episodes in the aggregate and rural agencies can go up to 3.2.
  7. Penalize agencies who do not bill for LUPA’s.
  8. Have the MACs (FI’s) perform a payment review on  a random sampling of claims in all agencies to make assumptions about the agency based upon OASIS data prior to paying claims to ensure accuracy of claims.  I am available at my hourly rate to assist agencies in this process which resembles RAC audits.
  9. Place all new agencies or agencies that acquire new provider numbers to  them on a 100% percent prepayment review of claims.
  10. Get rid of the therapy thresholds.
  11. Tighten up the face to face encounter time frame so that all patients except those who have just been discharged from the hospital must be seen within 14 days of admission..
  12. Allow Nurse Practitioners to sign plans of care.

It is possible that one or two of you are sitting there wondering how I ever became so brilliant and are willing to stand up and fully support these recommendations.

It is equally possible that some of you think I am knitting with one needle or that my IQ  roughly equals room temperature this weekend.

As such you would all be wrong.  These suggestions have already been presented to Congress by The Limited Partnership for Quality Home Health Care.   Click on the link to view the eight (8) members of The Partnership.  Is anyone surprised by anyone on the list?

In case you think that Bill Borne and his friends are just trying to mess with me, I encourage you to read their petition to congress.  It describes an entire proposed Act of Congress called the SHHIPS Act.

I have never had an act of congress – even proposed – named in my honor.  I want a Planet Wackadoo Act that eliminates stupid and/or greedy people from health care.    Better yet, what about a Put Patients First Act that prohibits determining care based  upon arbitrary numbers that coincidentally benefit the Elite Eight at the expense of the group of the other approximately 6,000 home health companies in the country?

As the week goes by, I will share my thoughts on the individual recommendations.  Meanwhile, we have a voice.  If you have any strong opinion about the SHHIP  – even if you disagree with me, use your constitutionally guaranteed right to be heard by those you elect to office

Now, go for a long walk, get some tea and clear your head.  We have work to do.

The Ugly Step Sister



Mandy Estes, Haydel Consulting Services LLC

Okay, so it probably wasn’t nice of me to put Mandy’s photo near the Ugly Step Sister title.  It is a coincidence, I promise.  I was going to introduce Mandy to you as I published her first post for our blog but I think she did a pretty good job of that herself.  Mandy can be reached via email any time you have a question or comment.  I hope you appreciate her unique take on things as much as we do.


For those of you who don’t know me, I am Mandy Estes. I have gotten a chance to meet some of you lovely nurses out there when I visit, and the best part of my job is meeting new people and getting to “visit” as we like to say here in south Louisiana. I have worked in homecare for a while now for a LARGE company and a small company and now I am blessed to be employed at Haydel Consulting. Can I say I love my job? Who wouldn’t love their job, if it sometimes consisted of writing a blog about the results of a Medicare 101 quiz? Regulations and tests make me giddy.

Throughout my home health career I have familiarized myself with state minimum standards, but I had not sat down and actually read the federal guidelines from front to back until recently. If you haven’t either, you should at least get started. Below is a link to them, it contains very valuable information and will only make your agency more successful. So, let’s get back to the subject at hand.

Observation and assessment. I want to call it the ugly step-sister to teaching and training.  Overuse of observation and assessment is like sending and engraved invitation to Medicare that reads,  “Hey, Medicare send the contractor to look at my charts!”

I don’t think anyone was too sure what to do with question 46, because the guidelines are somewhat vague when it comes to continued observation and assessment after the golden 3 week time frame. I could quote the guidelines verbatim but I don’t want to bore you all so much that you unsubscribe to Julianne’s funny and informative blog on my first attempt.

In a nutshell, the guidelines say this is justified as a skill when there is a risk for complication or exacerbation, but in addition the nurse is evaluating for modifications in the treatment plan. This means they actually want us to do something about the problems we are observing and assessing, not just stand around and write a detailed nurse’s note of our findings. We have all done it; even me.

Make a plan then take action by writing a case conference or calling the doctor’s office. In order to meet criteria, the plan of care must change.

The guidelines specifically address that a longstanding pattern of watching and waiting is not reasonable and necessary.

Let’s all make a pact to read section 40.1 of the federal guidelines focused on skilled services. If you will learn something you didn’t already know and maybe you can share it with the rest of us.  Experience tells that if one person missed something, chances are a lot of people did.   Education is a powerful tool and in our industry education is a must! Stay tuned, there is more to come.

Bill Borne, CEO of Amedisys Responds

Today, for the first time, I am going to present to you factually false information on my blog.  I do not know which information is false but I have received a lot of conflicting information from various places.

The delay in posting Bill’s response is a result of the fact that Bill’s initial response did not satisfy me in that I do not understand what he means about rebasing and then staying the cuts in 2014 and how this could possibly be good for the industry.  I fully agree that there is a lot on the financial and political side that I do not understand.  But within that email, Bill writes:

My colleagues, which are not an exclusive group, are working together with the whole industry to help stay the damage by working on positive messaging. These organizations are open to anyone who wants to step up to the plate in the industry and invest their time and money.

This came after the email from Keith Myers who said that the Alliance for Home Health Quality and Innovation are not in the business of lobbying.  I took Bill’s note on ‘positive messaging’ to be a euphemism for lobbying so I contacted him and gave him a chance to clarify his position.  Bill also received Keith Myers response to my original post which stated emphatically that no lobbying or legislative activity occurred.

That resulted in a phone call from Bill last Thursday.  During that conversation, he was adamant that Keith was one hundred percent correct.  He also said that perhaps I was confused.  There are and were multiple organizations out there and perhaps, I found information about the wrong group.  It is a sad fact for me that such a scenario is extremely possible so I found the lobbying reports forwarded them to Bill.  It was not my goal to discredit him personally so I offered him an opportunity to reconcile the lobbying reports with his position.  I did not hear back from him until late Friday afternoon.  See for yourself if he explains the lobbying reports.

September 30, 2011

To the Editor,

Last week, Reuters published an article that quoted me as calling for the government to provide home health providers greater clarity concerning reimbursement rates, in which the reporter noted that Amedisys and other publicly traded home health providers were lobbying Washington to accelerate the rebasing process. This article has generated a lot of attention, and I have received many questions seeking greater clarity concerning my comments. Accordingly, I wanted to take this opportunity to clarify my position regarding these matters.

As you may know, a report by the Moran Company from earlier this month analyzed the potential impact of CMS’ proposed 2012 reimbursement cuts and concluded they would lead to negative Medicare financial margins for 52.3 percent of all home health agencies in the U.S. This report can be found on

As the Reuters article reported, it is true that several members of the home health industry have formed the Alliance for Home Health Quality and Innovation dedicated to improving the nation’s health care system by supporting research and education to demonstrate the value of home-based care. However, the lobbying efforts referred to in the Reuters article were not, as stated in the article, undertaken by the Alliance, but rather by another group called The Partnership for Quality Home Healthcare which represents more than 1,800 community- and hospital-based, non-profit and propriety home health and hospice agencies nationwide and NAHC to develop innovative reforms to improve the program integrity, quality, and efficiency of home health care for our nation’s seniors.

Amedisys supports both the Alliance and the Partnership, and has also been a long-standing supporter of NAHC, which represents all home health care providers.

We invest our time and energy in these efforts to protect patient access to home-based health care for the more than 3.2 million Americans who rely on us. In doing so, we improve patient lives and the health of the Medicare system by keeping our nation’s chronically ill seniors out of the hospital and other more expensive facility-based settings.

The point I made to the Reuters reporter is that, despite the significant cuts in 2011 and 2012, our industry continues to face additional threats from many different sources, in the form of rate cuts, accelerated rebasing and calls for the implementation of co-pays, leading to great uncertainty about the future. Without a predictable and reliable long-term source of revenue, it is very difficult for any company—large or small—to form or implement a successful business plan or make the long-term investments necessary to support a healthy, sustainable organization.

In speaking with the Reuters reporter, I was speaking on behalf of myself and Amedisys only, not on behalf of the Alliance, the Partnership, NAHC or any of my colleagues. I personally support the effort to press Washington to provide our industry with a comprehensive reimbursement plan that we can be certain will be in effect for the long term. We deserve clarity on just how far the cuts will go. We need clarity so that we can plan ahead for mission critical business decisions such as hiring talent and investing in new clinical programs. If we leave rebasing totally up to CMS, each year through 2017 we will be forced to operate in uncertainty, taking us away from investing in patient care and instead worrying about which shoe will drop next. This uncertainty is simply not tenable—for any of us, or for our patients.

In my opinion, without the type of proactive initiative being spearheaded by the Partnership, we will certainly get an additional reimbursement cut in 2012, and again in 2014 when mandatory rebasing is implemented. The intent of my statement was to have the industry endure only one reimbursement cut, that we would have a say in and that would take place now, and that would be in effect for the long term, so we can operate our businesses with some certainty and confidence about the future.

I invite and encourage all home health care providers to help our industry by being active with any of the organizations formed to help increase awareness around the work we do helping and healing people each day.

We should not be divided. We need to have a joint effort to protect home health care. Our patients are depending on us to come together and protect their access to care.

Sincerely yours,

William F. Borne Chairman & CEO, Amedisys, Inc.

As mentioned previously, there is something factually false on this blog.  I am not in a position to know if Bill, Keith or the Lobbyists in Washington are the ones who have provided factually false information.   Bill and Keith can’t seem to get their stories to correspond on whether or not the Alliance actually engages in in any political activity or lobbies.   Read Keith’s very clear statement about the Alliance here.

If you read Bill’s statement carefully, you will see that he didn’t actually deny that the Alliance lobbied.  He said, “However, the lobbying efforts referred to in the Reuters article were not, as stated in the article, undertaken by the Alliance, but rather by another group called The Partnership for Quality Home Healthcare.”   So if the Alliance didn’t take on lobbying efforts referred to in the Reuters article, what efforts did they undertake?  Here is the lobbying budget for the Alliance of Home Health Quality and Innovation for the past four years.

This is the composition of the Alliance of Home Health Quality and Innovation from their form 990 filed in 2009.

On the Alliance’s 2009 Form 990 signed by , an IRS document required to be filed by all non-profits, the second page states, as attachment 2:  (bold lettering mine)

2009 was a transition year for the Alliance.  The Alliance has reorganized its working groups to address:  research, education of policymakers, internal and external communication, memberships, relationships with other professional organizations, quality and technology and innovation.  It also established working relationships with key policymakers at CMS, MEDPAC and other public and private organizations.  The Alliance has also held educational sessions for federal officials on the value of the home health benefit.

My understanding is that lobbying is an effort to gain political influence.  Truthfully, there is nothing wrong with that.  When a group of passionate people who openly state their purpose and do their best to persuade policy makers to make changes, the results can be amazing.  Going back to that little form 990 again, we see that simply joining a group does not give you an opportunity to facilitate change.

The Alliance shall have two classes of members:  once class of members with voting rights and the other class without voting rights.  Only members with voting rights may designate a representative who shall be eligible to be elected as a Director (it being understood that not all voting members shall be entitled to have a representative to serve as a Director).  The board of Directors may establish different dues categories and member designations in each class and shall otherwise determine all other rights and obligations of the members.

The Alliance also had to list its board members on the IRS form 990 in 2009.  This is taken from the IRS form 990 which exempts this organization from paying taxes.  Keith Myers signed the form.

Bill Borne Chairman and President
Ron Malone Vice Chairman
Val Halamandaris Secretary
Bill Yarmouth Director
MikeBayada Director
Chris McInnis Director
Keith Myers Treasurer
  • Once you get answers to some questions, even more arise.  Those that come to mind immediately are:
  • How can the lobbying reports be reconciled with the statements Bill and Keith made?
  • Is there a meaningful difference between ‘establishing working relationships with key policy makers at CMS, MEDPAC and other public and private organizations’ and lobbying?
  • Bill states the Alliance is open to all.  I have a whole lot of emails from home health agencies all over the country who state they never heard of it until last week.  If it is open to all, how much does it cost to join?  How much does one have to pay for voting rights?  What did the current members pay and is that public information?
  • Does NAHC have voting rights?  If so, on what scale?  If the voting rights of NAHC are proportional to Amedisys and LHC representatives, it stands to reason that the entire industry is not being represented proportionally.  If so, the name of the organization should be changed to, ‘Alliance of Really Big Home Health Companies’ .
  • If any topic arises that NAHC could be outvoted on by the large corporate entities, NAHC doesn’t belong in the Alliance, period.  That’s Julianne’s opinion.  No one else’s.
  • Do the members of NAHC know that their organization is part of a small group of very large players chaired by Bill Borne?
  • How much of NAHC’s membership dues went to pay the dues for being a member of the Alliance?
  • Bill proudly states that the Partnership for Home Heathcare represents more than  “1,800 community- and hospital-based, non-profit and propriety home health and hospice agencies nationwide and NAHC ….”  If you add up the number of agencies owned by Amedisys, LHV, Gentiva, Almost Family,Bayada and the VNA, I wonder how close the total is to 1800?  NAHC has 33,000 members according to their literature.   Which ones did NAHC choose to support?
  • Why is the Alliance for Home Health Quality and Innovation not listed on the NACH website under the affiliated organizations page?
  • Oh, and can somebody tell me who the Partnership for Quality Home Healthcare is?  The  information I know for certain is that they have a very large lobbying budget.  Nowhere on their website is the name of a manager, director, contact person, etc. mentioned.
  • Would the Avalere study emphasizing the benefits of home health have been more credible if the members of the Alliance hadn’t have paid for it?  It is understood in academic worlds that conflicts exist but conflicts of interest do not discredit a study nearly so much as the non-disclosure of said conflict.  By hiding behind the cover of the Alliance, a very expensive study was paid for by the largest home health care companies in the US.  I think that is relevant information.

As interesting as these questions are, nobody owes me an answer.  It is the agencies who compete against the larger publicly traded companies that need answers.  It is the 3,3000 home health agencies who are NAHC members that deserve to know these answers.

I encourage your comments.  However, since this is my domain, I could be held responsible for anything  published here.  I will withhold any comments that are overly insulting to any one individual or that make accusations that I cannot independently verify.  My goal is not to ‘attack’ any one individual or company.  My goal is to alert you to the fact that we have a limited number of large organizations, including NAHC that are making decisions for us all.

We have a ton of stuff to get done in the next couple of months in order to prepare for 2012.  But as far as this blog goes, it’s time to turn our focus back to what really matters.  We have to take care of our patients and keep them out of the hospital.  We have to endure cuts in payment but we will not compromise care.  We are nurses and given a roll of duct tape and a paperclip, we can bandage wounds, perform emergency tracheotomies, kill germs, and keep our patients quiet so we can provide the covered skill of teaching and training.

What’s Your Average?

I have had a lot of questions this past week about lengths of stay for home health and what they should be.  One large company in our area has begun mass discharging at several locations throughout the state causing my clients to worry that maybe the big company knows something that my smaller clients do not.  Another client has a very short length of stay and wants to know if they should extend it.

If you want to know the facts as I understand them, the Zone contractors are looking at agencies with excessively long lengths of stay.  The clients that I have had this year average around five episodes per admission.  What’s more is that the Zone contractors look at total length of time on service regardless of the number of admissions.  Many of the clinical records we review have multiple admissions and discharges.  So, if you think by reducing you average length of stay by discharging and readmitting will fool anyone, you may be right but it won’t be the Zone you fool.

There are various published numbers about the average home health length of stay per state.  The Southern states where both income and education are lower than the national average tend to have average lengths of stays of around 2.4 episodes per admission.  Some of the Northeastern states where money and education are not in short supply have a much lower length of stay.

But, I really don’t care about what your average is.  People hear that their length of stay is average or below and they breathe a sigh of relief and go on about their business.  I had an agency where most patients were on service for about a year.  However, a cardiovascular surgery group referred several patients a week to the agency who were only seen for three visits.  Their average length of stay was quite acceptable.  The reality is that most of their census consisted of patients who did not meet eligibility criteria.

To be sure, every agency has a patient that continues to come up with new ways to challenge the nursing staff.  They are admitted with DM but right before discharge they fall and break their hip.  After therapy gets them back on their feet, they have a small MI.  Later it is a stroke, etc.  As nurses, we cannot and should not look at an arbitrary number and discharge a patient because they have been on service for two years.  And even one episode is too long for a patient who is not homebound.

As most of you know, I am an information junkie.  I love the numbers and they tell me a lot about clients.  But when it comes to taking care of patients our concern shouldn’t be length of stay.  There should be no mass discharges to lower averages.  The only questions that matter are:

  1. Is the patient under the care of a licensed physician operating within his scope of practice?
  2. Are the services required by the patient reasonable and necessary as defined in Chapter 7 of the Medicare Benefits manual?
  3. Is the assessment and the care plan of the patient accurate and sufficient to guide care?
  4. Can you provide the services?
  5. Can you document the services?

Oddly enough, it is question number five that most agencies get stumped on but I digress.

If you can satisfactorily answer all five of these questions upon admission and recertification, the patient should remain on service.  Regardless of the length of stay, any patient discharged requiring home health care that is covered by the Medicare Home Health benefit is being shorted the benefits that they rightfully deserve.

Numbers give us a place to start looking.  It would be rare indeed for an agency that only keeps eligible patients on service to have a length of stay of five episodes per admission.  Upon investigation of a new client, I will certainly keep numbers in mind as I review clinical records.  However, my recommendations to the agency are made based upon the patient’s needs and conditions.

Does following these guidelines mean that the Zone folks won’t come looking for you?  Probably assuming the same guidelines were in effect for the past three years.  In addition to Zone contractors, remember we have RAC’s, state surveys, accrediting organizations and numerous other regulatory bodies who are more than welcome to visit an agency at any time and look at your records.  Be ready.  All it takes is one disgruntled employee to file a complaint or a surveyor who didn’t get enough sleep the night before to make trouble for you.  You have no control over that.  What you can control is your ability to respond successfully to any sort of scrutiny.

Questions?   Post below or email me.