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Posts tagged ‘julianne haydel’

Company 1


Take heed

Suzanne May, age 61, served as the administrator of a hospice referred to by the Feds as Company 1 for more than a decade She was a both a registered nurse and a certified hospice administrator. She signed a plea deal admitting to fraud on December 3, 2019 and now faces five years in prison followed by three years supervised release, a $250,000.00 fine and to top it off, a $100.00 special assessment. Hopefully, her lawyer can negotiate a deal where the special assessment is knocked off of the overall penalties.

Altering Legal Documents

To keep it short and simple unlike the official documents, Ms. May has admitted to:

  1. Using white-out on a Certificate of Terminal Illness. If you can’t figure out why that might be a problem, it’s best that you resign now.
  2. Adding dates to Notices of Election after the clinical records were requested from Medicare. I do not know how Federal Investigators knew when the dates were added.
  3. Ms. May relieved some patients of the burden of initialing forms by adding their dated initials to forms. The Feds are alleging that it is not possible to sign and date documents after death.

In an impressive display of organizational skills, Company 1 employees, led by Ms. May, kept a log of all changes made to the documents after the request for records was received.

This audit, performed in 2017, followed a 2015 audit in which close to $400,000 was returned to Medicare. As a certified hospice administrator Ms. May knew what was required of the hospice in order to be paid. And, to her credit, she made sure every detail was complete but only after her clinical records were requested by Medicare. Timing is everything.

Look Again

This post teaches you how to go to jail. Free meals, a warm place to sleep and a break from your needy relatives may be your ticket to jolly holidays. Surely the worst prison food is better than fruit cake and squash casserole.

In no way am I condoning the actions of Ms. May. I also recognize that the criteria for payment is sometimes preposterous. Claims for reasonable and necessary care provided to eligible beneficiaries are denied payment every day but that is a subject for another post.

In this case no patients were harmed as a result of Ms. May’s actions. Nobody dies from a date added to a document after they die. If jail is your ideal vacation, this seems to be the way to go if you don’t want any patients to be hurt along the way.

If you wish to remain home with your loved ones, I assure you that no matter how tempting it is to add a date to a form because the patient didn’t, and you know the correct date and personally witnessed the patient sign the form, it isn’t worth it. When a physician doesn’t date his or her signature and you know when the orders were signed, adding the date seems more like a courtesy than a felony but you would be wrong in making that assumption.

If this sort of behavior was evident on a state survey and a plan of correction to the state was required, it would probably include an educational piece like, ‘The DON will hold an inservice to teach the nurses things that they already know but didn’t do.’

If you are finding these problems during clinical record and billing review despite teaching the nurses repeatedly it’s time to try something new.

Cut your employees some slack. Home health and hospice nurses who provide excellent care to your patients are worth a little extra time. Review their paperwork with them as it arrives at the agency – which usually occurs before the time (and possibly the patient) has passed to get an ethically dated signature. Help them develop habits.

On the other hand, if a nurse blatantly commits fraud, investigate first and then terminate them. You are also obligated to report them to Medicare and their State Board. A good orientation will ensure they know the rules. Protect your nurses and the agency by providing a complete orientation including compliance. 

Do not bill (or alternatively, pay back the money) if you have found out that a nurse was taking shortcuts. It is painful to take the right steps but not as painful as the quarter million fine Ms. May will pay (plus the assessment fee).

If you are a visiting nurse, you know the rules. You know what to do and mostly you get it right but it only takes a couple of bad care plans or notices of election to cost an agency tens of thousands of dollars.

More concerning to me is the probability that some nurses are encouraged to ‘do what it takes’ to get billing out the door. Without using the words, ‘go commit fraud’, some employers leave employees feeling like their jobs are on the line if they hold up billing. If you feel that the only way to keep your job is to fill in the blanks omitted by a patient or a physician, I guarantee that unemployment is a better option.

Everything else aside, ask how Medicare knew the documents were altered by Ms. May and friends after the patient died. The Feds are not psychic. They did not have a seance summoning J. Edgar Hoover who revealed the exact time that dates were placed on documents. They obviously knew something that was solid enough for them to request 100 charts.

I’m willing to bet that Company 1 is not the real name of the hospice and that this story has just begun. Until we find out more, do yourself and your patients a favor and do things the right way. If you are preoccupied with compiling charts for an audit, care to your patients will be compromised. I’ve seen it too many times.

As always, your comments are welcome or you can email your thoughts.

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UPIC


I admit that I was a little hopeful, if not disillusioned, when the new UPICs came to my attention.  After verifying that UPIC was not a ZPIC with a typo, I thought that maybe this was a special type of audit where you got to pick the charts you wanted to be reviewed like some people pick their own lottery numbers.  No such luck, I’m afraid.

UPICs are Unified Program Integrity Contractors.  UPICs will carry out program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching[i].  The primary objective of the UPIC is to identify fraud and abuse and make appropriate referrals.  Other agencies recoup overpayment and address recommendations to law enforcement addressing criminal or civil charges.  They can also recommend suspension of payment.  Whether or not the agency is notified in advance of the payment suspension depends on if the UPIC thinks it is possible that the provider will change it’s billing habits if it knows that payment will stop.  Think about that for a minute.  Who wouldn’t change their billing habits if they knew payment was coming to an abrupt halt?

UPICs, like ZPICs can request clinical records, verification of licensure, copies of claims, etc.  The most recent UPIC request I read included a host of new horrors that may not be available and/or are too cumbersome to send.   Here’s a short recap of some of the new things but remember, they can always ask for more or even go to your office to visit.

  1. Copy of the face sheet. I have never used this term in home health or hospice, but it is basically patient demographics and insurance information.  People who have experience in a hospital are likely familiar with this term.
  2. Copy of Medicare card and state identification card (driver’s license or state ID). The logistics of getting a copy of the Medicare card and state identification card involve too many opportunities for loss and theft that I don’t recommend it even if Medicare wants it.  However, Medicare and other payor sources lose money daily when somebody loans (rents) their Medicare/Medicaid card to someone else.  Some software systems allow you to post a picture of the patient on the face sheet.  DNA and fingerprints are not necessary, but the end of the earth is not too far to go if there are any doubts. 
  3. Authorization of benefits. This is almost universally included in the consent form given to patients.  Take a quick look and ensure that somewhere on the consent it says that the patient or representative authorizes the agency to bill Medicare for services.  It would hurt a lot if this statement was inadvertently omitted when all those changes were made to the form relative to the new Conditions of Participation.
  4. EHR Audit Trails. In most systems, these audit trails are cumbersome to obtain and require someone to print or save the audit trail for each individual document.  In one system, the audit trail can be over 100 pages for a single document.  For a long time, there was a vendor who provided audit trails on request, but the agencies were not able to run them.  If you get a UPIC, consider the burden to your agency and call the person who signed your UPIC letter.  It kind of makes paper charts seem appealing again.
  5. OASIS to include the start of care, the resumption of care certification prior to and after the dates of services noted in this request and the discharge. I’m not entirely sure what this means.  To the best of my knowledge, patients aren’t certified after Resumption of Care unless the patient was in the hospital at the end of the episode and there is no change between the recertification assessment (not mentioned) and the ROC HIPPS code.  If an agency has a reasonable hospitalization rate, this is a rare occurrence.  Plus, there are numerous other bullets in the list that mention OASIS assessments.
  6. Travel Logs. Some agencies don’t have travel logs.  Some don’t pay mileage and others pay a flat ‘trip fee’.  I would think a visit log would be more useful to the UPIC but in the two page request, that wasn’t mentioned.

There are many more entries in the UPIC request but even though the length of the list is daunting, it is repetitive.  Laboratory results are requested on page one and all diagnostic tests are requested on page two.  There are individual entries for all hospital documentation, Inpatient records, Inpatient records to support start of care, inpatient records for hospitalizations during the episode, emergency room visit notes and the history and physical.  The best advice I can give is to be careful when delegating the tasks on the list, so you don’t have multiple employees all printing OASIS assessments.

The good new is that most of you will not find yourself in the undesirable position of being the target of a UPIC. If you are one of the unlucky ones, well, it’s not luck that brought you the unwanted attention from a UPIC.  The data analytics are very sophisticated and there is nothing random about the selection of charts (which makes me wonder why a copy of your Medicare Census is included in the list of documents required from the agency.  They know who your patients are.)

That doesn’t mean that your agency is operating outside of coverage guidelines.  It does mean that cloned notes, poor coding, lack of OASIS skills and care plans that are copied from one episode to the next will be under the spotlight.  This results in paying money back to Medicare and additional scrutiny which may extend to your referring physicians who might then begin referring patients to your competitors because they don’t like attention from Medicare any more than the rest of you do.  I do not like it when care is provided to eligible beneficiaries gets denied because a nurse is a little too eager to show off his or her new cut and paste skills.  It’s not like the agency can recoup their paychecks.

Questions?  Comments?  Do you have any experience with UPICs?  Post your comments below or email us.  We need to know now so we can understand them before they become obsolete.

[i] From Noridian Healthcare Solutions

Walmart Humana Merger


While nurses like us and other clinicians have been worrying about patient care, documentation and the new CoPs, Walmart and Humana have been getting cozy in the back room working out the details of yet another mega-deal.

The idea has an upside. A full 90 percent of Americans live within 15 minutes of a Walmart. That could go a long way to eliminating any access to care problems. Walmart’s drug prices are often less than competitors’ and could possibly be lower if they were the preferred pharmacy for Humana. Folks could see a physician or nurse practitioner, ask that their scripts be electronically sent to the pharmacy to be filled and go shop for everything from an oil filter for their car to Roma tomatoes while they wait- how convenient.

This sounds so good that maybe the good people involved in this potential deal are blind to the downside. Or, maybe they have never been to a Walmart.

Why do you go to Walmart? I go because stuff costs less. I do not expect sales associates to ask if I need help or because they play catchy background music. I dont expect anyone to help me pair cheese and fruit although to be honest, Kraft singles go with just about anything. I go to Walmart because stuff is cheap and in return, I lower my quality expectations. Have you ever compared a Walmart T-shirt to one from The Gap? Gap T-shirt’s make me happy. I would have to be sedated if I found a better T-shirt.

Walmart employees tend to be good people but the retail giant’s recruiting strategy is putting a computer in a conspicuous spot in the store to interview prospective employees. There is rarely just one person answering the questions so they must be hard.  To be fair, Walmart offers mostly entry level positions – starter jobs. I have never worked for Google or Microsoft but I don’t think this is how they filter through countless applicants.

I have to ask myself if this is the approach they will take to hiring the health care professionals that staff the Walmart and Humana clinics. ‘Our Mediocre doctors and nurses are the backbone of our clinic’, their tagline might read. ‘We’ve lowered our standards so you can pay less’. Do you want a mediocre practitioner in a starter job taking care of your child or grandmother?

And if someone has the flu, a standard script (computer generated from Humana’s algorithm) is probably all that’s needed for a patient who will spend the next 45 minutes infecting everyone else in the store. Watch as Walmart clinics go viral. Literally.

When flu season comes to a halt, things get trickier. As a recovering Walmart shopper, I am confident when I say that pretty much every one in the store is a potential patient. Unlike Whole Foods where you may run into your Yoga friends wearing yoga pants, the Walmart shoppers squeezed into a Spandex Lycra blend are not practiced in the art of Ashtanga.

And Walmart goes out of their way to perpetuate an endless supply of patients. Ramen noodles sell for a dime a piece but it is cost prohibitive for low income families of four to eat a meal including boneless, skinless chicken breasts. Red beans and rice, a perfect protein thats easily affordable always has directions to add sausage which enhances the flavor as much as it plumps up those thighs. The cheap high fructose corn syrup disguised as fruit juice costs only a fraction of the price of the real stuff. In the South where Roman Catholic values prevail, grocery bills rise each time a sibling is added and these low prices are appealing even if they kill folks eventually.

What happens if one of the Walmart shoppers/victims with a history of eating on the Walmart plan

falls out in the store? Can you see the utter chaos as the mediocre care practitioners try to read their CPR pocket card and perform chest compressions simultaneously? How many potential patients will remain loyal to Humana after they see a patient die because, after 22 attempts, there were no more IV catheters left in the crash cart and emergency drugs could not be administered.

If this deal goes through, it will be a failure for everyone involved. Humana may save money on drugs but by the end of a year, Blue Cross will emerge as the premiere insurance carrier by default. Physicians and Nurse Practitioners with restricted licenses rendering mediocre care may be an effective cost savings approach but without being surrounded by competent colleagues who can teach them or at least watch their backs, million dollar payouts will become the norm.  After all, there will be a lot of witnesses.

Walmart needs to spend their cash on improving the experience of their employees and Humana might think about increasing the speed of paying claims. And I need to be able to sleep without worrying about receiving Walmart branded healthcare.

But the most important reason to speak out against this deal is because it is nothing more than business – a way to make money.  They could have respected us enough to at least pretend they were aiming to meet needs of the people who made them successful in the first place.

Your thoughts?

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