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Posts tagged ‘home health care’

Tell Me a Story

When working with ZPIC clients, it is important to remember that Zone Contractors have been told to address eligibility more so than quality of care. Quality of care issues are to be sent to local licensing agencies and QIO’s if found in excess in a chart. Keeping this in mind, there are only a limited number of factors that make a patient eligible for home health:

  • They must be under the care of a physician
  • They must be confined to the home
  • OASIS data must be accurate and timely
  • Care must be reasonable and necessary
  • Must need skilled nursing care on an intermittent basis for reasons other than obtaining blood
  • Must be a Medicare beneficiary

Mostly the eligibility requirements are easy to prove. If there is no signed order, the patient is not considered to under the care of a physician. If the patient’s clinical record does not consistently reflect homebound status, the patient is not considered to be confined to the home, etc. OASIS data is either transmitted or not. And if your patient isn’t a Medicare Beneficiary, you simply will not get paid. But what about demonstrating that the patient requires reasonable and necessary care for an intermittent period of time?

The best way that I have found to demonstrate that the patient is eligible for reasonable and necessary services is to write a good 486 summary. I understand that not everyone enjoys writing but anyone can put together a good summary. If your grammar and spelling stink, it does not matter. There is no eligibility requirement stating that good grammar and spelling are required to get paid. Furthermore, while templates can be a useful tool, it often happens that every single 486 summary in the agency looks pretty much identical. Templates also lead to summaries reading like this: During this episode, the patient experienced daily pain. The patient required assistance to bathe. The patient did not require assistance to transfer. The patient ambulated with an assist device.’ This ‘story’ tells me nothing that I want to read over and over again as I review 30,000 pages of documents for a single ZPIC audit.

So let’s try something different. I believe that you can write an excellent summary if you merely answer the following questions:

  • Why is the patient being admitted or recertified and what is the primary diagnosis?
  • On admission, what happened prior to admission to instigate the referral? (Patients do not just wake up and decide to join a home health care agency as though it were a gym.)
  • What secondary diagnoses affect the patient’s ability to participate or respond to the plan of care?
  • What medications does the patient take (list names only because full orders are on the 485)
  • What additions and deletions to the Medication list occurred during the last episode?
  • Is there any significant lab work or diagnostic test that was performed last episode? (Please do not write that NO lab was drawn last episode.)

Next Section – what did the patient look like last episode?

  • Give overall impression of neuro status. Was patient mostly oriented? Was the patient confused?
  • Did the patient have pain? If so describe. If the patient was taking PRN pain medication, state how much was taken and how often over the prior episode.
  • Did the patient have any heart or lung sound irregularities? If not, simply state that patients chest remained clear to auscultation and there were no murmurs, rubs or extra heart sounds appreciated.
  • Did the patient have any issues with his gut? Diarrhea? Constipation? Nausea? Vomiting? If not, state the patient experienced no GI distress. If so, try to tie it to a reason such as a drug side effect, a virus, etc.
  • Did the patient void okay? If incontinent, mention the skin integrity of the areas affected by incontinence.
  • What did the patients legs look like? Pedal pulses bilaterally? Skin flaky or peeling? Describe the patient’s gait.

Next Section – What happened that was extraordinary last episode? A fall? An illness or exacerbation? Surgery? MD visits with changed orders? Gimme something here, folks.

Next Section – What did you do about all the irregular findings?

  • When was the doctor contacted?
  • Were no orders given?
  • Did the MD change the plan of care?

Final Section:

  • What on earth do you think you are going to do for this patient?

Answer that question and you have demonstrated reasonable and necessary. Now the occasional missed weight and missed visit won’t count quite as much in a payment review.  As always, we welcome your comments and emails.

Flu Season is Here!

Are you interested in saving a few lives? If your aspirations are less lofty, what about improving your outcomes?

You can accomplish either or both of these objectives by gearing up for flu season if you haven’t already. Since it is officially flu season, the OASIS dataset questions about the flu will no longer be answered as N/A on admission assessments.

Last year, everyone got excited about H1N1 flu. There was good reason to do so but the threat to our patients was less than that of the regular flu. It seems that elderly people had some resistance related to a 1950’s flu epidemic. This year, the flu shot combines protection against the ‘regular’ flu as well as H1N1 eliminating the need for two injections. How easy is that?

Each year between 30,000 and 40,000 deaths occur as the result of the seasonal flu. The overwhelming majority of these deaths occur in the elderly. Our Medicare patients can receive the flu vaccine at no out of pocket cost. If you have patients who have to pay for flu vaccines, be aware that the cost of a flu shot is less than one trip to the drug store to buy Nyquil, Advil, chicken soup, Gatorade, saltines, etc.

So get busy! If your agency does not administer the flu vaccine, encourage your patients to find someone who does. Get a list of providers. It may be as simple as a trip to the local Walgreens. And don’t stop with patients. Encourage family members who reside with your elderly patients to be vaccinated as well.

Me? I think it is cool to be able to offer immunity. It kind of makes me feel like a federal agent.

Looking at Cash


I am by education and preference a nurse. I serve as a clinical consultant to my clients. I have no education or experience in business and I have absolutely no aptitude for accounting. So, why do I look at cash?

Actually, there are only limited numbers I look at when it comes to cash. The first and most important number to me is the length of time it takes for an agency to bill a RAP. Although from a billing perspective, RAPs are simple, there are numerous clinical and patient care functions that must be complete before dropping a RAP.

  • The patient must be admitted/recertified
  • All paperwork is submitted to the office
  • A plan of care is built
  • The physician has been contacted
  • Data entry has done their job
  • Billing has all the relevant information to drop a RAP

If RAPs are delayed beyond seven days, chances are one or more of these processes are being delayed. This might mean that admissions are not turned into the office in a timely fashion or that data entry is behind in their work load. Whatever the cause, it probably means that the patient is being seen by visiting staff who do not have access to a plan of care. Considering that 25 percent of all hospitalizations occur within the first week of home health care, these processes could dramatically affect the patient’s level of care.

In a perfect world, five days is reasonable for a RAP to be dropped. It is a very lofty goal and is usually only attainable in a very stable, well staffed agency with electronic documentation that eliminates much of the data entry. In smaller paper based agencies where staffing is limited, I am content with 7 days. But, the number of days it should take is not determined by me! It is determined by your agency.

End of Episode claims are expected to take a little longer to get out of the door. Physician signatures are required and there is only so much that an agency can control when it comes to physician signatures. Additionally, a thorough billing audit should be performed to ensure that each claim meets the standards of the payor source.

However, if the end of episode billing audits are uncovering a vast number of orders that need to be written to correct frequencies, medications, etc., then they will be delayed even further. Even the most cooperative physician in the world will not sign orders that haven’t been written.

Two weeks is generally acceptable for End of Episode claims. Anything beyond that suggests that visit notes aren’t on charts and orders haven’t been written contemporaneously with the services provided.

When it comes to RAPs and EOEs I also get concerned when the numbers are too low. Could that mean that important clinical and regulatory steps are being overlooked?

The amount of money tied up in RTP and ADR status can also tell me a lot about the overall efficiency of the agency. RAPs should never be reclaimed because EOE claims haven’t been billed timely but I see that more frequently than I should. An excessive number of RTPs could mean sloppy billing processes.

So, if you are a nurse in a management position and you don’t know these numbers, you may be operating from a compromised position. If your billing department cannot tell you these numbers off the top of their heads with reasonable accuracy, they are not working within a system that provides benchmarks for performance. If no one can tell you these numbers, I can almost assure you that your agency has problems.

If you have any questions or comments, I always welcome them in the comment box below or you can email me directly at

Our Financial Future

Usually I am an eternal optimist but I have had a few setbacks as we are facing cuts to the Medicare Home Health Benefit. Even though home health is responsible for less than four percent of the Medicare budget, Congress voted to reduce home health payments by 13 percent (43 billion) over the next ten years. Their stated purpose is to reduce waste and inefficiency. The New York Times article can be found here.

Obviously my first thought is one of pure outrage. The politics of health care reform can be overwhelming and frightening for all of us who take care of patients or work to support those that do provide hands on care. And yet, in spite of my repeated pleas to Mr. Obama and being very frank about my opinions, it appears as though I have been largely ignored. Imagine that.

So what can we do? Do we stage a grass roots effort and hope that we can raise a few thousand dollars for a lobbyist that can never compete against the millions of dollars funneled into special funds in exchange for congressional votes? That is one option and it isn’t a bad one even though it may prove to be ineffective. But while we are writing letters, arguing loudly and doing everything we can to protect our industry, we must face the truth that home health care will likely take a hit in the near future. And if the false prophets of hope and denial are proven to be unsuccessful, we will be left with an enormous challenge.

But it’s a challenge we can meet! Every day I read in the newspapers about how bad the economy is and yet, the global numbers really don’t tell you the story of any one person’s finances. The same applies to the health care budget. Cuts will be hard but manageable if we begin to prepare now.

And the great thing about preparing for impending financial cuts is that the preparation involves all the same things we should be doing already to be efficient. Here are some steps you can take now.

  1. If you are leaving money on the table, stop. It is not unusual to find an agency leaving between five and eight percent of money on the table due to inaccurate OASIS scoring. Those same agencies have the opportunity to reduce their cuts by bringing their baseline up to the ethical maximum. And agency currently leaving eight percent on the table will only suffer a five percent cut if they work on their OASIS scoring now. And who would mind an eight percent raise even if the cuts never happen?
  2. If you haven’t already done so, look into converting to point of care computers. Although the investment of time and money is huge initially, the investment will pay off when you can reduce back office staff and all the quality of your data is impeccable. This will happen with or without cuts.
  3. Look at staffing patterns. If your agency does not use LPNs, consider doing so for stable patients. Consider reducing or eliminating nursing visits in therapy only cases. Review every process that each person in your agency performs and see if it is really necessary or ‘if it is something we have always done’. If it falls in the latter category, consider eliminating it for a period. Try to reduce the use of PRN nurses so that your agency can provide more efficient care with staff who regularly see patients.
  4. Take a really good look at the software you are currently using. If possible call for staff training. Many agencies are using software systems that have been in place long before most of the staff was hired. It is common to find that current software is able to provide tools and information that you were not aware of in the past.
  5. Slowly develop disease management programs. I am not referring to the pathways of the past that provide nurses with a set recipe for care. I am referring to education, tools and resources for nurses to take care of diabetics, CHF patients, PVD, etc.
  6. Invest in a wound care expert. This isn’t as dramatic as it seems. Find one or two nurses in your agency that excel in wound care and provide them all the education you can and try to have them see all patients with wounds at least once. Many wound care vendors provide wound care education at no cost to your agency.
  7. Teach care planning and goal setting. Eliminate the ‘random’ visit where we go get a set of vital signs and aimlessly assess the patient. All visits should be planned to work towards a specific goal!

Finally, breathe. That’s all. I came into home health during IPS. If you don’t know what IPS is, drop to your knees and say a prayer of thanks. If you remember IPS, you know that we have been through worse in the past and we will make it through anything the future throws our way.

Don’t get me wrong. I don’t want the cuts any more than the next person. But if I want to survive as a nurse in home health, the only option I have is to preserve my integrity and help you get ready for the future. And if we get lucky and healthcare reform is put on hold until we retire and fruit flavored rain becomes the norm, we will still provide better care and make more money. Can’t beat that with a stick!

As always, I welcome your comments below or you can email us here.

We Need Your Help!

As we plan future projects, it occurs to us to ask home health agencies to give us their input on what kind of education fits best into their routines. Please take just a minute and answer the following, single question poll. Results are available for all to see.


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