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Posts tagged ‘Jacques Roy’

A Gross Distortion of Truth

Implemented in 2011 as part of the ACA, the Face-to-Face requirement was mandated as a way to prevent Medicare fraud.  Well known cases of fraud involved agencies paying physicians who have never seen a patient to sign orders.  The best known case is that of Jacques Roy in Texas who defrauded the government of 450M by running an orders signing factory. There are more cases like this but these agencies are in the minority.  Although it is inconvenient at times, it should not be too difficult to satisfy this requirement to prevent additional fraud and abuse.

    1. The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.
    2. The certifying physician must document the encounter either on the certification, which the physician signs and dates, or a signed addendum to the certification. It may be written or typed.
    3. It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type. It is also acceptable for the documentation to be generated from a physician’s electronic health record.
    4. It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

I received a copy of a face-to-face document last week and posted it below.  This patient has Parkinson’s disease, congestive heart failure and chronic pain.


As many of you can guess, it was denied.  Nobody doubts that the patient was eligible for services or that the services provided were reasonable and necessary.  The physician saw the patient on the 26th as indicated in the documentation and also daily while he was hospitalized.  Physical therapy was indicated as the reason for services in a section of the document I could not clip without revealing personal health care information.

So why was payment denied for this patient who met eligibility requirements and received much needed covered services?  The physician did  not write a ‘narrative’ because the silly doctor thought it was self evident why someone with diagnoses of pain, Parkinson’s Disease, congestive heart failure who kept falling despite use of an assist device was confined to the home.

This particular document was appealed recently so it was easy to find but I have scores of them in my computer from numerous clients from all over.  And most will be denied.

Medicare states:

The face to face requirement ensures that the orders and certification for home health services are based on a physician’s current knowledge of the patient’s clinical condition

Nobody could possibly have more knowledge of the above patient’s condition than the physician who saw the patient daily in the hospital and then signed a face to face document.  Shame on that physician for failing to use verbs and pretty language to describe the patient better.  Perhaps he thought the document to which the face-to-face encounter was attached would be read.  Wrongo.  As with all statutory denials, the work is over when the claim is denied.  Why take your time to read an entire chart or even the care plan if the claim does not meet billing requirements.

Adding to this are the thousands of face to face encounters that meet all requirements and are denied regardless.  When this happens, an appeal is sent to the QIC (the next level of appeal) and often the QIC finds that the face to face encounter did satisfy all requirements but another reason for denial is found.  This tactic essentially robs the agency of one level of the appeals process.  

After working in post acute care for all these years, my faith lies in home health and hospice.  We have not lived up to our potential as a sub segment of the industry, but we are getting closer every day.  It will be a moot point when congress and other policy makers hear information painting a picture of our industry as blatantly fraudulent and unable to follow even the simplest regulation designed to prevent fraud.  That is my concern.  We will be somehow be left behind as new budgets are developed and our reputation is tarnished.

And to this day, I believe that if we did live up to our potential, congress would be lining up to ask how we wanted to be paid instead of  dismissing us as criminals in scrubs.  We will never live up to our potential as long as education, consulting, inservicing budgets are dedicated to teaching nurses how to review the face to face document to fund payroll.

Most importantly, I want copies of all face to face documents that have been denied if you don’t mind sharing.  You can sanitize them by removing personal health information or I can send you a HIPAA agreement so you can send them as is.

I am losing faith that our government, the one who wants to control 20 percent of our economy with the ACA is being truthful when they state that the purpose of the face-to-face encounter is to combat fraud.  Color me cynical but I see it being bastardized as a way to deny providers payment for covered services rendered to eligible providers. 


Payment Suspended for 78 Agencies

By now, everyone has heard of the very busy Dr. Jacques Roy who had more home health care patients than anyone in the entire united states and is accused of causing greater than 345M in false claims to be billed to Medicare.

Have you read the actual indictment, though?  It names at least two RN’s as well.  That really doesn’t bother me because I don’t count nurses who pay homeless people money as colleagues.  I do so hope they lose their licenses.

What was tucked in at the bottom of the most recent article that came across my desk is that 78 home health care providers have apparently had their payments suspended pending the results of a full investigation.

This sounds extreme and it is because of the number of agencies that have payment suspended.  However, these are  not the first agencies who have had payment suspended because of ties to known or suspected physicians.

One client was assessed an overpayment of greater than 3M.  This is small time compared to the 345M that makes headlines.  Nevertheless, payment was suspended.  Another agency with the same medical director likewise had their payment suspended.  The second agency was not in a position to hire me due to the profoundly impaired cash flow.

Check your docs, folks.  After these agencies had funds suspended I began researching the docs for all ZPIC clients.  It is amazing what was found.  The problem is that the state board of medicine doesn’t actually report on issues while they are still under investigation.  In fact, the medical director referenced above was in jail for 8 months before the OIG added her to the exclusion list.  The state board of medicine still lists the license as active and having no disciplinary history.  (Jail doesn’t count, I suppose.)

I got the good stuff the way I get all the good stuff.  I googled the docs.  The press love photos of physicians being escorted out of buildings by men in uniforms.  If there are handcuffs involved, it makes the first page.

If a physician has a restricted license, be sure that you are fully aware of the restrictions.  Some physicians in recovery are not allowed to prescribe scheduled meds.  Often a nurse will write all meds a patient is taking including scheduled meds from another physician.  When the restricted doc signs the 485, he has just violated his license.  I had never come up against that before and frankly, I do not know how these will fare during review.  I am not hopeful, however.

For what it is worth, the client who was assessed the greater than 3M overpayment arranged to borrow the money from the bank so that Medicare could be paid back and the agency would be able to function until the appeals level of the audit.  Medicare said, ‘thanks but we are not restoring your payments until after the entire investigation is complete.

In other words, a year or longer.  That means that there are effectively 78 fewer agencies in Dallas this week.

On the bright side, you may get a really good deal on a licensed only agency but you will not be able to bill until you establish a new provider agreement with Medicare.  Remember, if you purchase a provider and assume their provider agreement, you have assumed their debt to Medicare.  You would think that would be obvious but it’s worth stating again.

So, check your docs.  If you find out any good stuff about docs in my area (Louisiana, TX, Fl, AL), send me a discreet email at so I can ensure my clients are not unwittingly involved with someone who will get their cash suspended.

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