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Posts tagged ‘Jnon Griffin’

Battle Scarred

war against fraud

Normally, I try not to be so very outwardly hostile towards CMS but lately, it seems as though the feds don’t really need to justify intruding on my privacy or the bank accounts of legitimate health care providers, so, whatever. The fact is that the face to face document has become the equivalent of a Weapon of Mass Destruction by CMS and their contractors.

You, as a provider, have a lot to lose if you do not honor the provider agreement signed with Medicare.  What everyone forgets is that Medicare signed the very same agreement which guaranteed you payment for rendering skilled care to eligible beneficiaries.

Rightly and wrongly, Palmetto GBA has been denying claims for months with no consideration of the care provided to patients.   This week, CGS announced it planned to follow in the footsteps of PGBA which will radically increase denials for those providers.

The abuse of the Face to Face requirement by CMS contractors has gotten so out of hand that it has become abundantly clear that they are looking for any reason to deny providers regardless of the care that eligible beneficiaries received.

To be clear, there have been agencies who paid a medical director to sign orders blindly for the sake of convenience.  There are other physicians, like Dr. Jacques Roy who sold his signature and his soul for money.  The intent of the document was to ensure that patients were seen by their physicians who were then willing to sign their name to a document stating the patient needed care and was homebound.

So the rationale was sound and initially, it was not much more than an inconvenience for agencies to get an additional document signed upon admission.  Beginning last year, the face to face requirement has been bastardized as a weak excuse to hold onto money that good providers earned providing skilled care to eligible beneficiaries.

There is not a day that goes by that I don’t hear from someone about a denial related to face to face document and more importantly, it is rare that a day goes by that I am not made aware of very real fraud.

I have no idea why Palmetto and CGS have decided to wage a campaign of hostility towards providers.   In the ‘good old days’ when FMR was about the worst thing that could happen to an agency, the solution was simple.  Document well and follow the guidelines.  Lately it doesn’t seem to matter how good or bad your chart is.

One physician wrote in the reason homebound section, the ICD-9 codes for Parkinson’s Disease and scribbled ORIF.  I get that the document did not meet all the requirements for a narrative.  Also included on the document was the patient’s age (85), the fact that he had PEG orders.  Perhaps I am reading too much into the information.  Maybe it is reasonable to believe that an 85 year old patient with Parkinson’s Disease, and a hip replacement could leave the house unattended to play bingo.   Or softball.

Another physician wrote the reason for home health was paralysis.  Skilled nursing was ordered for catheter care and so the claim was denied.  The MD did not realize the nuances of home health coding apparently and the claim was denied because we can’t fix paralysis.

We can’t fix lazy and stupid, either.   It certainly relieves Medicare contractors of the burden of reviewing records if a face to face is not completely accurate or grammatically correct and it has become abundantly clear that many of the records sent are not even read.

The sophistication of the Medicare IT has grown exponentially in recent years.  They are able to tell if the physician who signed the 485 is not listed as the patient’s physician in the database but they cannot see a Part B claim from a physician and determine that the patient was seen timely.  Do they really believe that all those patients admitted from the hospital were not seen by a physician?

Not one single Medicare beneficiary has received better care because of this insane demand on agencies.  In fact, time and resources that could be used to teach nurses about the new Diabetic protocols (bet you didn’t know they were published) or otherwise enhance the clinical skills of nurses are being devoted to getting the physician to document one encounter multiple times to ensure the agency gets paid.  In some cases, the agencies are simply completing the form for the physician’s signature.  They get paid.

I strongly encourage you to play by the rules but also to fight every single denial for a face to face to the level of an ALJ.  The days when the cost of appeal was taken into consideration when determining whether or not to fight it are now part of our rich home health history.  Fight everything until an ALJ or two sees how very abusive these practices are.

Don’t call or email me for a couple of weeks if you have something confidential to say.  I figure after about two weeks, the feds will see how very boring my life is and remove the wire taps. And try to find some time in between ADRs and running down face to face documents to, you know, take care of a patient or two.  Remember them?  Patients?  Elderly, lots of DME and a ton of pill bottles; none of which contain the pill she thinks she takes for sugar.

Please tell us about any face to face horror stories below or email them to me privately.  If you are a client and anyone asks who your consultant is, tell them Jnon Griffin or Lisa Selman Holman.  Just sayin….

Thanks to All!

I had the most wonderful opportunity to show off what we all do for a living during the last week of March.  Hugh, a reporter living in England wanted to find out how we Americans did home care and health care in general and ended up visiting with us and some of our clients.  Before he arrived, he had time in Washington and visited with NAHC members and had the opportunity to stop by the Supreme Court while the historical hearings on Healthcare Reform were ongoing.  Having never paid a physician bill or an insurance premium, he had to have been bewildered at all the commotion.

Upon arriving down south, he got to meet some of my colleagues, coworkers, and coworkers.  Ray Banker, Demetrix Tolliver and Lorraine Wells all visited from local agencies.  Jnon Griffin of Comfort Care in Alabama came to represent fans of the Red Tide.  Poor dear.  In case you think the South was overrepresented, keep in mind that Bobby Robertson from Healthcare First visited as well.  His clients are spread out across the nation and he has unusually keen insights into our industry.

Ray Banker of Audubon Home Health made a big deal about having tickets to the hospital’s annual fund raiser which was featuring the 80’s band, Foreigner as the entertainment.  He pointed out several times that there were no remaining tickets left so even if we wanted to go, we would not be able.  I enjoyed the picture of Hugh with the band at the hotel bar later that evening more than a well balanced person should.

So, yes, I am grateful to all.  My visitor learned more than he ever wanted to and we learned a lot from  him as well.  (As an aside, this man who has never paid a physician bill or health insurance premium comes from a country where only 8 cents of each dollar is spent on healthcare as opposed to 15 cents in the US.)

The fun part came later.  Imagine if you were from another country where it is cold (by our standards) and rainy all the time.  You fly into the states and hang out at the Supreme Court and NAHC and then arrive in the South and experience Southerners – US -for the first time.

Imagine that you have never seen a bayou, eaten a crawfish, touched an alligator or met a Katrina survivor.  Thanks to Tory at Bayou Health Care, that is exactly what happened on Thursday.  That’s a pretty big day by any standards.

The Katrina refugee was actually a patient with Medicare and one of those Medicare gold advantage plans.  After falling off a ladder and breaking is pelvis, he was sent home at two am in what can only be described as frank, abject, maybe horrifying pain.   Technically the pain only occurred when he moved but it was difficult to get him out of the car and into the bed without moving him.  He is very lucky he is not married to me or he would still be in the car with his bottled water and his urinal.     He was instructed to go to the MD within five days but couldn’t because his wife couldn’t handle the enormous task because of Multiple Sclerosis.  Tori was working on it and a visit was scheduled to occur the day after we left – closer to 30 days after the fall.

Then we saw the alligators.  I thought they were so friendly because they were cold but maybe not.  Our guest noticed bullet hole in the head of one which completely dispels my illusion that the gators just liked me.  Doesn’t that say volumes about my assessment skills?

Apparently there is a television show called Swamp People filmed in Pierre Part.  We met several family members but ‘Troy’ was out getting some crawfish so we browsed the gas station in front of the Alligator fridge but none of us purchased  a ‘Choot ‘em’ tee shirt.  I feel sort of bad for the relatives of tourists bringing these home to family and friends in places where ‘Choot ‘em’ is not  the phrase used to describe the act of discharging a weapon. They must think the Tee Shirts were discounted because of a screen print error.

I don’t eat crawfish unless it comes with a cocktail made from benadryl, solumedrol and epineprine which wasn’t on the menu at Landry’s but Mandy is a pro at teaching others how to eat crawfish.  We are currently applying for Continuing Education credit for the course but so far have had a lot of documents thrown back at us for ‘clarification’.  See photo.  How could anyone need further clarification.

We stopped briefly at the Virgin Island – singular; not to be confused with the string of islands in the West Indies – to show Hugh snakes and turtles which are not common in England, apparently.  He started getting a little anxious and wondered how he was going to explain away this 10 minute side trip as work.  After I figured out that he was serious, I clued him in.  This was home health.  We don’t always stop to pet the gators but they were right there at the gas station anyway.  Our Katrina victim and Medicare patient may have seen a bit extreme but all of our patients have unique histories and challenges.  And in South Louisiana, there are only so many days when you actually want to get out of an air conditioned car so we took advantage after driving all day.

So our reporter will have many political twists and turns that affect our industry and be able to write with confidence about the National Association as they rallied – yet again – for a targeted approach to fraud and abuse.  The grandeur of the US Supreme Court in the midst of three days of historical hearings on health care reform is decidedly noteworthy.  But down the bayou, (or in the high rise, the mountains or the inner city) is where the patients can be found and wherever there are patients, you will find good nurses.

This is who we are – nurses taking care of people in their homes in the face of enormous challenges that have never been considered in Washington.  Home health isn’t about politics or fraud and abuse.  It is about finding a ride for a patient to get to the doctor.  It’s about holding the hand of someone with a new diagnosis of cancer or trying to get the multi-pill jar patients seem to prefer sorted out.  Its about teaching complicated medications to patients who really just want to get better and don’t care about anion gaps and insulin resistance.  It is also about being a part of a community that may or may not include alligators and snakes, highrise buildings with unreliable elevators, icy mountain roads or too many narrow alleys roped off as crime scenes.

Seems to me that if a reporter from another continent can take the time out of his life to ride down the bayou visit patients, so can the politicians and lobbyists who believe they know what is best for the Katrina refugee who relocated after the storm and can’t get to the doctor in this family oriented community where he has no family.    I wish the Supreme Court Justices would ask  Tory what she thinks of the individual mandate.  And I am very open to taking Kathleen Sebelius for a ride down the Bayou.  If anyone sees her, tell her to give me a call.

Special thanks to my happiness engineer at WordPress.  I tried to upgrade some services when my domain expired and what I wanted to do wasn’t possible.  As it got later and later and my frustration grew, I emailed the support crew.  Elizabeth, my happiness engineer didn’t just send me complicated instructions; she took care of the complicated domain mapping and such.  I wish there were more happiness engineers in the world.