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Denial Shock

It’s a patently bad idea to share my frustration regarding people who can make or break my career on the internet but after this weekend of working denials, I’ll take my chances.

The first denial I dealt with was the result of a ZPIC audit.  Somebody from AdvanceMed called a patient on the telephone and asked him if he drove. He assured her that he did.  The telephone interviewer, having heard what she wanted without assessing the patient, denied close to 30k in claims.

I actually visited the patient.  I also read his plan of care and medication list and couldn’t help but notice that he was on three or four pain meds that would make it very difficult, indeed, for him to get a driver’s license, but you never know.  The drive to his house included a 15 minute stretch on a country highway, another two miles down a gravel road and then the dirt road.   The trailer itself sat on over  an acre.  He had to climb five stairs to get inside and his scooter which was referenced in the denial was under the carport rusting.  It seems that it is fairly cumbersome to operate a scooter in a mobile home where three adults and three children live. 

But, what sold me on the homebound status, other than his five back surgeries, his lack of a vehicle or a license, his extensive medication list and the challenging physical environment in which he lived was the diagnosis of schizophrenia.  As early as that morning he reported having a conversation with his sister who died tragically two years ago.  He said he usually took Zyprexa and Seroquel but he didn’t that day because he had gone to the doctor to talk about back surgery.

The next denial was for $3,500.00.  It involved a claim with 7 skilled nurse visits, 9 therapy visits and a few home health aide visits.  The reviewer at Advance Med noted that there was no order for the visit to discharge the patient from therapy services.  I went back through the original scanned copy sent to the Zone and found the order.  So what?  Everyone makes mistakes and it was difficult to find.

The claim was not downcoded, you understand, but completely denied.  In full.  

My client appealed to Palmetto who upheld the original denial.  My job this weekend was to explain how the Home Health Prospective payment system worked to entities contracted with our government to monitor the integrity of Medicare payments.  That annoyed me.  I get paid by the hour so maybe I over reacted but I assure you that there are far more useful things I could be doing for clients. 

Lack of therapy orders for another client was the target of yet anther inane denial for a different client.  The client appealed AdvanceMed’s decision to Palmetto who reviewed the two signed orders (the 485 and the physician signed therapy eval and care plan) and agreed that AdvanceMed overlooked both orders.  However, the decision was noted to be ‘unfavorable’ (I love that word) because there was no distinction between short term and long term goals on the plan of care.

They were right.  What can I say?  Who really wants to hear that the entire course of therapy lasted only three weeks?

The most uncomfortable denial I worked this weekend was a claim that was part of a ZPIC request that my company prepared for a client.  They were paper charts pulled from old storage and our job was to put them order, verify signatures and notes, identify any outstanding vulnerabilities, scan 35,000 pages of documents and get them to the Zone on time.  I know you won’t believe this but we, uh, sort of…, well….. we made a mistake.

The claim I was reviewing had orders in it from 2010; a full year after the 2009 denied claim.  I missed it.  AdvanceMed missed it.  Palmetto missed it.  And now its back to me.  I found myself in the awkward position of pointing out that we sent in documentation that implied orders were written in March of one year that were actually written 12 months later.  Not only did Haydel Consulting totally miss the ball on this one but so did AdvanceMed and Palmetto, GBA.  I would like to take this moment to point out that unlike AdvanceMed, I do not have a 105M contract with my client. 

What can you learn from this? 

  1. At least once episode, fully explain the patient’s homebound status.  Being confined to the home due to pain and the need for help to leave the house will do on visit notes but once an episode, put it all together in context in case clinical record is requested for a payment review.
  2. If any claim is requested contains therapy, go buy a red Sharpie and draw a circle around the orders.  Make sure each page of the chart is numbered at the bottom.   Reference the therapy orders by page number in your cover letter.
  3. Include that the patient will win the Nobel Peace Prize prior to his or her death on all therapy care plans.  That way you can google the winners each year and monitor progress towards goals.
  4. The regulations state that all orders must be dated.  Apparently, it doesn’t matter what date you put on the orders as long as they are dated. 
  5. Haydel Consulting Services is not perfect or known for exploiting our warm and friendly relationships with Medicare contractors because we don’t have any.  Hire us anyway because we get results.  Somehow. 

Should I send an invoice to AdvanceMed and Palmetto or let my clients pass on my bill to them?  Maybe CMS could pick up the tab for educating their contractors.

I can’t wait to see what comes up next.  You’ll be the first to know if I am not in jail fighting accusations of healthcare fraud because I sent in orders that were a year late. 

Please keep me posted of any creative new denials you receive.

Billing Questions

In order to bill Medicare for home health services, all notes, orders and clinical documentation for the episode must be signed and in the medical record prior to dropping claims. Sounds simple, right? Homecare 101. And yet, our whole industry is plagued by rumors. Like old wives’ tales some of these false beliefs become so embedded within an organization that nobody has a clue that they might be doing anything inappropriate. Here are two of the billing myths I have heard lately:

  • Since agencies are paid per episode, it doesn’t matter if all visit notes are in the chart prior to billing. Only therapy notes are required to be in the chart prior to billing. And yet, here is what the OIG suggests as part of a plan to ensure that agencies comply with Medicare billing guidelines:

Provide for sufficient and timely documentation of all nursing and other home health services, including subcontracted services, prior to billing to ensure that only accurate and properly documented services are billed; Emphasize that a claim should be submitted only when appropriate documentation supports the claim and only when such documentation is maintained, appropriately organized in a legible form, and available for audit and review.

  • If an order is written after an episode ends such as when auditing clinical records, it is not necessary to wait for signatures because the order was not written during the duration of the episode. Here is how Palmetto GBA tells us to avoid denials:

When responding to an ADR, verify orders for all services billed are included with the medical records. Ensure physician orders, for all services billed, are obtained prior to providing the service and prior to billing Medicare, and are submitted for review. Ensure all oral/verbal orders are countersigned and dated by the physician before the final claim is billed to Medicare. In the event the physician fails to date his/her signature, write or date stamp the date the order was received back from the physician. The stamp date must include the word “received” and should be in black ink, as red and blue ink will not photocopy.

Even though it is not mandatory that agencies have a compliance plan, there are many good reasons to implement one. Chief among them is a promise by the Office of the Inspector General that sentencing guidelines are influenced by the presence of a compliance plan. Regardless of whether your agency chooses to implement a formal plan or not, these billing guidelines are mandates and must be followed. To do otherwise is to put your agency in serious regulatory or financial risk.

We always welcome your comments and questions below or if you choose, you may email us at As always we are available to assist agencies in implementing a corporate compliance plan. If you choose to go it alone, please refer to the OIG sample compliance plan.

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