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Posts tagged ‘julianne haydel’

Sep 8

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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.

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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. 

 

Aug 4

Face to Face–Your Results

A few weeks ago, you were invited to take a quiz on the home health requirement for face – to – face encounter documentation.  If you haven’t already done so, please go take the quiz now.

The results were interesting to say the least.  You know when a face to face encounter must be done and you are very clear about your (non) role in the creation of the document.  Where you fell off was in the questions regarding who signs the face-to-face document.  If your overall score was not what you hoped, rest assured that your colleagues are right there with you.

Here are some of the more interesting responses.

Less than 50 percent of you knew that if a patient died prior to the 30th day and a good faith effort was made for the patient to have a face-to-face encounter, you may still bill.  This is not a suggestion regarding how to get around those pesky MD’s who refuse to sign, by the way.

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The question that was particularly disturbing was a true/false question inquiring if it was true that the same physician who signed the 485 must also sign the face-to-face encounter document.  If you answered that question correctly, you are among a 35 percent minority.  A full 65 percent of you answered it incorrectly. (Green is good, pink is bad – I did not choose the color scheme.)

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Similarly, less than half of you knew that if the hospital documentation was used as the face-t0-face encounter it had to be labeled as such and the date of the encounter had to be included.  When you consider many of the discharge summaries, they often apply to the entire hospital stay.  A visit date must be identified and declared as THE day the encounter occurred.  image

Rest assured, other than these very three common reasons for denial, y’all knew your stuff very well. 

So what do these results mean? If I was paid by your agency to come in and teach y’all about the face to face encounter and after I left, you continued to get denied, would you consider me to be an effective teacher?

The truth is that Palmetto GBA is responsible for educating you on the face-to-face to requirements.  This is part of their contract with CMS. 

Here’s the part that keeps up at night.  If all of you were to learn exactly what a perfect face to face documents looks like and then you all taught ten people who in turn taught ten people, by the end of next week literally billions of people would know everything there is to know about the face to face document. 

And not one patient would receive better care because the physician forgot to label the hospital documents as the face-to-face document. 

Just sayin…  Palmetto GBA, take it for what it is worth but I respectfully suggest you might have a little more work to do in the realm of face-to-face document denials. 

Jun 13

4 Comments

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….

Feb 10

5 Comments

The Checkbox Patient

You say the pain feels like an elephant sitting on your chest? I'm sorry but that's not an option. Let's move on.

You say the pain feels like an elephant sitting on your chest? I’m sorry but that’s not an option. Let’s move on.

I get frustrated when I see people try to squeeze an entire person into a series of checkboxes.  This has gotten under my skin for a long time.  Apparently, Medicare agrees with me.  Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.

The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time.  I provided the bold text.

The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.

The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.

CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.

Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.

Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.

If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.

So, be wary of programs that do too much for the nurses.  If a program doesn’t require at least a short narrative, it likely will not get done.  If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.

Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information.  You need reports and communication.  You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.

You do not need any more denials.  I assure you.

Jan 1

9 Comments

You Do the Charting!

photo (24)

2013 is the year we quit talking and start doing.   If you are bold enough. you could be the proud owner of a Haydel Consulting Services flash drive.  Be the envy of your friends with this ultra sophisticated, data base storage device that has been proven secure and reliable and goes where you go.  Better than a cloud drive, the HCS drive doesn’t rain, snow or block your sunshine.  Mobile storage for mobile nurses!  All you have to do is attempt the documentation challenge presented below and enter your response in the comments section.

Challenge:  Consider the following information and write a brief but thorough narrative describing your care.  Your vital signs and assessment are performed and documented.

You are on call on a Saturday evening when a physician calls you about a patient.  You have never seen this patient but open up your computer and see that the patient is a 78 year old female with diabetes.  Secondary diagnoses include congestive heart failure, kidney disease and Alzheimer’s Disease.

The physician is concerned because the patient’s daughter called and said her mother was ‘acting out really bad’.  He wants a blood sugar and lab done to ensure her lytes are in range.  He also wants to know if she may be hypoxic and asks you to weigh the patient and get a pulse ox reading.

Your assessment is unremarkable.  Her fingerstick blood sugar after supper was 162.  Her pulse ox is 99 and her weight is recorded at one pound less than the prior week.  Vitals are good and the patient appears to be in her usual state of health other than the behavioral disturbances.  You ask the daughter what prompted her to call the MD and she reported that her Mother did fine all day.  She was confused but pleasant and content.  Her mother listened to music and folded a laundry basket of dish towels while the daughter cooked for a family gathering later in the week.

At about 6:30, the patient began showing signs of agitation.  Nothing seemed to work to quiet her anxiety.  The daughter gave her some xanax as ordered and tried to reason with her mother.   Twice the daughter had to go outside and bring her mother back indoors.  The daughter is genuinely afraid she will have to put her mother in a home.

So, you’ve drawn the lab and performed the assessment.  What else might help this patient and her daughter?  How do you document it?

The winner will be announced a week from Friday.  That means that if you have case conference or staff meeting between now and then, you can all practice ten days in a row.  There is no limit to the number of entries but they all must be original.  The grand prize will be chosen from all entries so it really doesn’t matter if you can’t chart a skill to save your life.  You can still win and after next Friday, you will know how to document at least one skill.

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