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Posts tagged ‘julianne haydel’

Dec 8

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This Gruber Dude

Who is Jonathan Gruber and why should you care?

Dr. Gruber is an MIT healthcare economist who served as a consultant for the ACA (aka Obama Care). He has a very impressive background that includes more than one Ivy League school and he also worked on the healthcare plan in Massachusetts. I think he is a democrat and he openly supports the ACA.

If you know anything at all about Gruber, it is probably that he called you stupid. Technically, he called me stupid, too but I didn’t take offense. He was speaking of the American Voter in an accent heavily laced with sarcasm. These insults were leveed during talks and lectures over the past couple of years and were dug up by some poor individual who was searching for a reason underlying the increase in his family’s insurance premiums. That’s important. Gruber did not stage a press conference to call us stupid.

Are we clear? He is an economist, likely a democrat and supports the ACA. He is fluent in sarcasm and clearly not a politician. He tells the truth as he knows it and economists generally find their truth in numbers.

What Gruber has said could completely unravel the ACA.

When speaking of a tax on high dollar insurance plans, he said, ““The only way we could take it on was first by mislabeling it, calling it a tax on insurance plans rather than a tax on people when we all know it’s really a tax on people who hold those insurance plans.”

On passing the healthcare legislature: “…lack of transparency is a huge political advantage. … Call it the stupidity of the American voter or whatever, but basically that was really, really critical to getting the thing to pass.”

These two quotations are inflammatory to the point of being entertaining. They make good headlines and gossip and tell a story. More important but less entertaining is what Gruber said about individual states that don’t implement an exchange.

“If you’re a state and you don¹t set up an exchange that means your citizens don’t get their tax credits. But your citizens still pay the taxes that support this bill.”

This is the heart of the case going to the Supreme Court. The law suit headed towards the highest court in the land is all about the tax credit offered to the individual states. The law reads that states that do not set up the exchange will not be entitled to tax credits which would affect 37 states. Proponents of the ACA state the language was obviously a typo and that’s not what the law really meant. Jonathan Gruber offered information to the contrary long before the case going to the Supreme Court was a reality.

If the Supreme Court rules that the law means what it says and they have a history of doing so, the only solution would be to change the law. As of November, half of the politicians who voted for the ACA are no longer in place. Oops.

I’m not sure that the citizens of 37 states want to pay for the healthcare of the citizens in other states while their own healthcare expenses increase.

Here’s where it gets really interesting. If the Supremes agree that the law means what it says and congress is not able to come up with a quick fix, how does that affect us?

The Face to Face documentation is a part of the ACA and if the law gets knocked down, were denials for the F2F unconstitutional as well? How about those restrictions on who can own a hospital? Is the hospital re-admission program part of the ACA?

What about all the people in the states who have no exchange? Will providers be paid? Will the insured get taxed?

The Supreme Court never implements anything. Rather, they determine if a law fits neatly into the constitution. If it doesn’t, it really isn’t their problem.

Tomorrow, Dr. Gruber is going before the senate for a grilling hearing. I will be watching and I hope you do, too, as you are able. We’ll be able to hear a little bit of the arguments we can expect to be brought to the Supreme Court. When they rule – probably next July, things could get very interesting.

Just so you know, and all….. I am much more inclined to trust a man with no filter than a politician trying to sell me something too complicated to understand.

Nov 24

3 Comments

Giving Thanks

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Wow.  What a challenge.  Thanksgiving is this week and it is only proper that I share with you all the ways we should be thankful.  I’m really struggling.

I could be grateful because I am appealing.  I spend most days at my computer appealing denials for clients.  I enjoy a good argument but the craziness of all these denials for claims for reasonable and necessary care given to eligible patients is overwhelming.  Worse than the financial hit is the overall disrespect of home health and hospice agencies.  If anyone wants to feel like a criminal, all they have to do is work for a home health or hospice. So I may be appealing but I am not grateful.  I would much rather be teaching and doing something – anything – that worked towards better care of patients.  Keep that in mind if you need an inservice or two.

I could be grateful that the Face-to-Face documentation burden has been lightened but I am not.  I guess I’d rather it be lightened than not but I just got ten or so denials this morning related to the requirement.  The Medicare Contractors are going to suck dry the opportunity to withhold money from my clients – and you, too if you do not happen t be a client– until the very last minute.  The regulations taking effect in January have no effect on past denials. 

I could be grateful that more Americans than ever will be able to afford insurance with the ACA but I am not.  The law is so complicated that I think there are only a handful of people who fully understand it and they are not elected officials.  Since nobody really understands it, it has become a dividing line between democrats and republicans who are voting with their party with no idea of how it will play out.  So, no, thank you.  I am not grateful for the ACA.

This doesn’t mean I am not grateful though – even at work.  Home health and hospice have been taken on a ride these past couple of years and you survived. 

I am so very thankful that I know people who are willing to get up and drive to a stranger’s house to adjust pain medications at 3:00 am. 

I know the houses where the water gets cut off for lack of payment located next to the crack house and you find it in you to smile warmly at the patient and show them the same respect that you would if you saw a patient at a $20M Manhattan apartment.

I know your kids are left without a parent during a special football game or school play because you cannot leave a patient in need but I am grateful for the lessen you are teaching to the next generation.  Taking care of others is an important job.  Compassion is a value that should be passed along to the next generation.

I am thankful for those of you who contribute to this blog and The Coders’; even when I don’t agree with you.  I appreciate that you have ideas you are willing to call your own and speak up about them.  You are prime material for patient advocacy.  I like that. 

I love the laughs, the occasional tears and how you make me feel as though I am one of you.  Because I am.

Thank you.

Nov 2

5 Comments

Change on the Horizon

The 2015 update to  Home Health PPS is considerable and provides for major and minor changes, plus a lot of interesting information.  Here’s the bullet points.

Reduction in Payment

No news here.  Everyone was expecting a decrease in payment.  It comes to approximately $81.00 subtracted from the standard episode rate.  The standard episode rate is that dollar amount which is adjusted by OASIS and other factors to find the final payment rate.  In contrast, the per visit rate has gone up slightly. 

Face to Face documentation requirements

A face-to-face document is still required but the narrative section has been removed effective January 1, 2015.  Within the regulations the effect of the Face-to-Face requirement has been described as follows:

  • The error rate for home health claims was calculated to be 17.5 percent.
  • The majority of home health improper payments were due to “insufficient
    documentation” errors. “Insufficient documentation” errors occur when the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation element that is required (as described above) is missing. Most “insufficient documentation” errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services, as
    required by §424.22(a)(1)(v).
      • CMS-1611-F  Page 37

Important:  All episodes beginning with an OASIS Start of Care assessment will require  Face-to-Face documentation.  While the risk of denial related to the narrative has been reduced, agencies will have far more opportunities to make an error.  This includes patients who return to service after being discharged and patients who were in the hospital over day 60 of an episode and must be readmitted for purposes of billing. 

MD/hospital documentation:  The regulations state that if requested, an agency must cough up the hospital’s documentation if the patient was admitted directly from the hospital or the physician’s notes that demonstrates eligibility.  This should be happening already but from reading clinical records, it is obvious that often the nurses caring for the patient are not reading the hospital documentation.  Do not wait until 2015 to add getting the MD records in the chart prior to billing.

Interesting and Important:  I think the following excerpt is saying that if agencies provide the physician with the information to support eligibility, the physician may use it if he or she signs off on it.   This is in stark contrast to not being able to help the physician compose the narrative.  Read for yourself and feel free offer your own opinion.

The initial assessment visit must be done to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The Medicare CoPs, at §484.55(b), require a comprehensive assessment to be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care, and for eligibility for the Medicare home health benefit to be determined, including homebound status. We would expect that the findings
from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician.

The certifying physician can incorporate this information into his/her
medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility. The certifying physician must review and sign off on anything incorporated it into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.

End in Sight

Twice in the Federal Regs, there is a directive that all patients whose care extends into a second episode, must be recertified with a documented estimated end in sight for skilled care.  I really thought I missed something in the proposed regs but Lisa Selman-Holman did not see it, either.  Regardless of who saw what, the directive is in place.  Be careful of ‘statutory’ reasons for denial.  This has the potential to be like dates, signatures, etc.  Once it is identified that a recertification did not meet requirements, a full denial can be issued.

Math

There are some changes to the payment calculations.  I am hoping that someone with a better head for math than myself with go through all the numbers and explain to us the difference.  Consider that a cry for help.

Data Submission

There has always been a provision in the Prospective Payment System for a 2 percent penalty for those agencies that did not submit OASIS data.  Nobody knew what that meant.  Did it mean penalties for no data submission or less than 100% data submission?  It has finally been clarified for agencies as 70% of qualifying episodes in 2015 with gradual increases over the next several years. 

Since it is now a requirement for payment that the OASIS data used to determine payment be in the state repository prior to billing, this new definition strikes us as ‘late’ for lack of a better word.  If you are not sure of your data submission status, call us now. You need help.

Value Based Purchasing

Value Based Purchasing is recycled Pay-for-Performance.  The actual indicators that will factor into any payment adjustments have yet to be determined which was common theme in the P4P predecessor.  Although this is not our first rodeo with the concept of Value Based Purchasing, this one may stick.  Keep your ears to the ground for more information.

These regulations run through 259 pages but like most, there is a lot of fluff and stuff inserted between the good stuff.  Take some time and read through the comments and look at some of the data.  We will be doing so as well and posting anything interesting or important we find.

Good luck.  It’s always an adventure when the regulations are changed.

 

Oct 28

2 Comments

Taking Care of Numbers

Medicare is talking once again about value based purchasing in home health.  This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically,  Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers.  Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes.  Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.

My mother had a heart attack several years ago.  My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine.  I told him to take her to the hospital.  He proceeded to tell me that her blood pressure on the other arm was quite different.  A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital.  He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.

At the hospital, he asked me what MI was.  Mama had just been taken in the back and there was no credible information that she suffered an MI.  After a detailed explanation, he asked why they put it on the form between first name and last name.  Still no coffee.  This was going to be a long morning.  Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.

I spent many years working in a cath lab.  Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting.  Finally, the doctor called me back and showed me the films.

Nothing.  All I saw was wide open vessels.  Mind you, I’m good at this.  I can spot a diseased vessel that most people miss.  I did not see anything.

He repeated the films several times and challenged me, ‘You still don’t see it, do you?’  Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit.  The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded.  He explained he couldn’t find it either which accounted for the delay.  He had to review the films and reshoot a couple of times to be certain.  Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.

I was relieved.  Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings.  All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.

A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church.  I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI.  Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her.  She was fine after she stopped it.

She did not need any of the three.  Her drug of choice for pain is old fashioned Bufferin.   I have almost had to admit her to detox for it any number of times.  Her cholesterol is within normal limits and her coronary vasculature was award winning.  She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.

Meanwhile, the hospital’s outcomes are keeping up with the Jones’s.  In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good.  Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.

I don’t have to choose as it turns out.  Medicare has already determined what pretty much every heart attack patient in the country needs.  With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.

What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital.  There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker.  There are side effects of statins including memory loss.  An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well.  The chances of side effects for Mama outweighed the benefits of treatment.

Treating the hospital’s outcomes should never be mistaken for quality care of individuals.  This is something we need to remember when our reported data is being evaluated for purposes of payment.

Sep 30

3 Comments

But Our Survey was Perfect!

The state has come through and scrutinized every piece of paper in your office, gone on multiple home visits and even complimented you on your Infection Control Program.  There’s absolutely no reason to be concerned when some ADRs are received from Medicare.  How could an agency as perfect as yours be denied payment?

It happens every day.  Trust me.  I hear about perfect surveys and denials in the same sentence almost every day.

State regulations often follow the Medicare Conditions of Participation.  If your survey was perfect or even just good, you have likely met the CoP’s.  However, off to the side, in another area of the manual are the Medicare Conditions for Payment.  They are separate and apart from the CoP’s because not all payor sources have these requirements for payment. 

They are:

  • The patient is confined to the home
  • The patient is under the care of a physician (or as we say in the south, under the doctor)
  • The patient has a need for recurring, intermittent skilled care.
  • A Face-to-Face Encounter must occur within a designated time frame
  • The patient is an eligible beneficiary
  • OASIS data has been collected and submitted.
  • The agency is certified by Medicare.

Most patients meet the homebound criteria but many patients do not have homebound criteria documented well enough to warrant payment.  In case you missed it, here is a post about how to document homebound status.   

The patient is under the care of a physician should be obvious, right?  Not so fast, grasshoppers.  Not just any physician counts.  It has to be one that is licensed in your state or your state must allow physicians from nearby counties in another state to write orders.  Each state is different so read your physician practice acts and call the board of medicine if you still aren’t clear. 

The way that Medicare determines that a patient is under the care of a physician is by looking at signatures.   For years, we were told that if the physician failed to date his or her signature, we could simply enter the date the signed plan of care was received by the agency.  They changed their minds on that one a few years ago but not everyone got the memo, apparently.  Everyone in the agency who sees plans of care on a regular basis should be taught to look for dated signatures.  The earlier you find an undated signature, the more likely the physician will be able to sign an attestation statement with confidence.

Recurring, intermittent services sounds like someone is trying to confuse you.  In short, you may not see a patient indefinitely and you may not arrange to see a patient only once.

Daily nursing visits must have a written ‘end in sight’ to daily skilled nursing care included in the documentation.  The single exception to this rule is daily visits for insulin injections.   You can document this anywhere but I like to see it under the frequency or in the goals section.  Similarly, you may not plan to visit a patient once.  Physicians may call and ask for you to go to the house to remove sutures or administer a flu vaccine.  These visits would not be covered under the Medicare home care benefit although you can give a flu shot.  If a patient dies, moves out of town or refuses services after the admission visit, you may bill for it because you fully expected to see the patient again.

I think we have covered, recovered and stripped bare the Face-to-Face documentation requirements in prior posts.  If you continue to have questions, read here. 

Skilled care is defined in the Medicare Benefits Manual, chapter 7.   I always have a copy on my iPad and my desktop but whenever I can, I go to the online version because changes are fairly frequent.  You can identify the changes by the red font.

Everyone checks eligibility right?  I seldom see a problem with that but when one occurs, it occurs in a very big way.  Usually, an unfortunate soul without Medicare or insurance will borrow someone else’s card.  Although you are completely clueless, it is still non-billable.  That means you have to give the money back.  If you find out about it before Medicare does, you have 60 days before the money is considered fraudulent (that applies to all overpayments).  Whenever possible, check identification on admission.

It seems that until recently, agencies sent OASIS data in one direction and claims in another and the two never met up and the penalty for not submitting OASIS data was very scarcely enforced.  At some point, the OIG got wind of this and jumped all over Medicare in a long and boring report last year.  Now now you will be denied on an ADR if the OASIS data has not been submitted. 

I think you will know if ever your agency becomes decertified so let’s just skip that one.  (Hint:  one big clue is the lack of payment.)

Your state surveyors do not know much at all about billing.  The Face-to-Face requirement is not a requirement for licensure.  In all likelihood, you probably know more about OASIS and coding than a surveyor does because they do not do it every day.  The state really doesn’t survey your length of stay.  The state wants to know if you meet the basic requirements to provide care for patients.  If you are still confused, consider that the state employees are paid by state taxes to protect the citizens of the state.  Medicare pays contractors to protect the trust funds (large piles of money) used to pay for the care.

If you have a perfect survey, it means that you are doing many things right.  In fact, if you get in trouble with your state agency, there will come a point in time where they will communicate with Medicare and your provider number will be at risk.  I’ve only seen that happen a few times by people who do not read stuff like this. 

Now think about all the reasons agencies have claims denied.  They are not included in your state survey.  And that is how you can have a perfect survey and still get denials or worse. 

Now you know. 

Questions and comments are always welcome.

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