Posts tagged ‘home health care; home health compliance’

Jan 12

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.

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.
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.
A letter will be sent to the agency for each claim that is under review.
You have 30 days to send the records to the FI.
This information is also available through the DDE (billing) system and I strongly recommend that you rely on DDE as opposed to the mail.
THE SECOND MOST COMMON REASON FOR DENIALS IS FAILURE TO RESPOND TO THE REQUEST FOR ADDITIONAL INFORMATION.
Once all of the letters have been sent, the ADR’s stop. The edit is put on hold until your claims have been reviewed.
Do not mistake this lull in activity as an indication that the MAC (FI) is through with you.
The FI has 60 days to review the clinical records and make a determination about your agency.
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.)
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.
If you have a higher denial rate, the dance continues for another round.
Education is provided by the MAC or FI during this time. It usually consists of memos cut and pasted from the Medicare Benefits manual.
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.

Dec 27

7 Comments

Cherry Picking

Every year my mother picks cherries. She doesn’t think twice about climbing on a ladder and reaching over the fence to the neighbor’s tree and picking all the cherries she can reach. She read somewhere that fruit that fell from a neighbor’s tree into her yard is legally hers. She insists she is merely assisting the cherries to fall gently to the ground on her side of the fence where they were going to fall anyway. Then when she gets enough cherries, she fills two big glass containers and pours vodka over them to make Cherry Bounce. I really don’t have a problem with that because my Mama is over 80 and if the worst thing she ever does is make Cherry Bounce with cherries of questionable origin, I think I can live with that.

Cherry Picking patients is another story all together. I am not a lawyer so I will not speak to the legalities of it, if there are any. I am not an ordained minister (if you don’t count the free certificate I ordered off the web just to see if I could) so I cannot offer you moral advice. I am, however, a long time participant of home health in various capacities at various companies and I assure you that I recognize sleaze when I see it.

We all know the agencies who visit patients right up until their benefits run out. In Louisiana, Medicaid patients are seen by one set of agencies in the first part of the year and another set of agencies in the last part of the year. We know of agencies who refuse expensive wound care patients and low paying Medicaid in other states. Proving it would be difficult but I cannot count the number of times that I have been in a client’s agency and a referral came from a discharge planner or doctor’s office reporting they had tried two or three other agencies before they could find someone to accept the patient.

Nurses, excluding the DON, often don’t have much of a choice over setting policies in an agency but we do have the responsibility to advocate for our patients. We can insist on timely discharges and responsible frequencies so that a patient will get the care that they need.

We can also insist that visits be increased when needed regardless of the cost to the agency. It is never appropriate for a financial person to bully a nurse into writing a care plan that doesn’t meet the needs of the patient. It is also not a financial decision to determine if a patient is ready for discharge or needs to be recertified.

Before I start interagency wars, I have experienced that good agencies often have some conflict between the clinical and financial departments. I see agencies thrive when both sides are firm in their positions and each side knows when to relent or compromise. As a nurse, I think every patient needs daily visits and the most expensive wound care products. As a businesswoman, I realize that nobody gets care if the agency cannot stay afloat. It is only when clinicians and ‘money dudes’ have mutual respect for each other that solutions benefiting both the agency and the patient are regularly discovered.

If you are competing against an agency who never compromises with the clinicians and consistently refuses care to expensive patients or low paying patients because of ‘staffing’ shortages, document each event that comes to your attention. If they occur repeatedly, send the information along to your state survey office. They have every right in the world to determine if the agency had sufficient staff for other referrals that day.

If you receive a referral that has been refused by other agencies for financial reasons, ask for the next referral as well. My friend, Ed Lakin, a Marketing Consultant says that too often we forget to ask for business. The referral source can always say no but at least you have made known that you are open to more referrals. (And I do mean, ‘ask’ and only after you have accepted the patient in order avoid the appearance of an inappropriate arrangement where you are bartering with patients.)

When physicians who are Medical Directors of other agencies only refer money pit patients to you to protect their interests, document your concerns. If it happens repeatedly, diplomatically confront him. Smile sweetly and be courteous while you let him know you believe he is behaving in a manner that is an embarrassment to his profession. Do not use those words.

I like making money. I love business. I work all the time to help my clients increase their margins. There are countless ways that it can be done but none of them involve being sleazy.

Sometimes, doing the right thing costs money. When a patient requires care, it will likely be provided. There is always a nurse who can be talked into seeing a patient with real needs. The question is which provider will lose money on the patient?

Hopefully, the same provider who is able to accept and admit high dollar patients will take a hit now and then. If not, the agency that does admit the patient is without a doubt the better agency. Of course, their outcomes may not reflect it because costly patients often are at higher risk for hospitalizations and since their competition only admits high profit patients, it stands to reason that their patients will have better outcomes.

If you have any solutions to this issue, please share them below or email us. It frustrates me when I see this happen and I get paid regardless. I cannot imagine the frustration agencies experience on a daily basis. All of my solutions usually result in long discussions with lawyers and tailors measuring for prison scrubs. Help your fellow agencies out here and provide some ideas that do not jeopardize licenses, marriages or freedom.