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Posts tagged ‘Mandy Estes’

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.

Deny, Deny, Deny

This horse will likely die of humiliation soon but please don't beat her. Her owners have put her through enough already.

It’s Mandy here.  Hope you all had a wonderful holiday.

So, we all know the old saying – Deny, Deny, Deny.  Well, apparently that’s what our zone contractors are so anxious to do.  They deny claims for the smallest little things like medical necessity. Whoever heard? Wink, Wink.

The truth is, these zone contractors get paid literally millions of dollars for ensuring that claims are paid appropriately. In order to make CMS feel good about al those millions of dollars, they have to offset the payment with a whole lot of denials. I wonder how they sleep at night?  Probably, pretty good laying on their big fat wallets.

But it doesn’t stop with the Zone.  Apparently, Palmetto and other MACs got jealous at all the attention the Zone contractors were getting and now they are flooding the market with ADR’s.  In some cases, the same agencies under a ZPIC audit are also getting ADR’s.  How can that be fair?  It probably isn’t, but we ain’t changing it so we have to live with it.

Palmetto GBA is so warm and fuzzy; they give us a list of the worst offenses.  Here are the most recently listed Top 10 reasons for denial:

    1. Documentation does not support homebound status.
    2. Lack of response to ADR.
    3. Information does not support medical necessity.
    4. Orders do not cover all visits billed.
    5. Unable to determine medical necessity b/c appropriate Oasis not submitted.
    6. Medical review HIPPS code change/Documentation contradict M item/s
    7. POC/Cert present and signed but not dated
    8. Dependent services denied because qualifying service was denied.
    9. Partial denial for therapy resulting in medical review HIPPS code change.
    10. Order not signed and/or dated timely.

What are we dealing with here?  Homebound, medical necessity, we know, we know.  Apparently, we don’t.  50% of this list is directly related to documentation.  Whether it be our Oasis, our skill, or our therapy notes, can we beat this dead horse anymore?

Attention DON’s and case managers! Calling all nurses and therapists! 

Big brother is watching.  We can no longer skate by with the minimum.  We must provide top notch care with top notch documentation EVERY, SINGLE visit for dwindling reimbursement.  What does that mean?  Only the best will survive, but we can do it.

Steps to take to alleviate denials:

  • Train staff based upon the most current guidelines not outdated belief systems
  • Make sure employees understand the definition of homebound status and how to document  it on every clinical note, including therapists
  • Don’t provide an opportunity for a medical necessity denial
    • Actually look at medicines every visit – truly groundbreaking idea
    • Develop working relationships with physician offices to open communication
    • document all changes to the plan of care
    • document all changes in condition
    • Ask for changes to the plan of care when necessary.
    • Always address caregivers in documentation – preferably by name.  Changes in caregiver status affect our patients.
    • educate all clinical staff to sign and date notes with a legible signature if you are not using electronic documentation
  • Train clerical staff to look for signatures and dates when filing as a double check system
  • Establish a follow-up policy for outstanding orders and stick to it.  Orders not signed within 30 days are not acceptable.  Hand deliver to the physician office if necessary.
  • Get a custom stamp that reads:  DATE YOUR SIGNATURE or something a little less subtle to put on MD orders and care plans

Everyone makes a few honest mistakes, but more than a few could land you in the slammer.    Be careful out there my fellow warriors.  Document, document, document!  Our nursing instructors were right!!

*Please note: No horses were actually hurt in the writing of this blog and I have never actually spoken to or met a zone contractor employee so I actually cannot vouch for their sleeping arrangements, personal appearances or opinions regarding home health zpic audits.  This is only a commentary and represents no actual employees of Zone Contractors.

The Ugly Step Sister



Mandy Estes, Haydel Consulting Services LLC

Okay, so it probably wasn’t nice of me to put Mandy’s photo near the Ugly Step Sister title.  It is a coincidence, I promise.  I was going to introduce Mandy to you as I published her first post for our blog but I think she did a pretty good job of that herself.  Mandy can be reached via email any time you have a question or comment.  I hope you appreciate her unique take on things as much as we do.


For those of you who don’t know me, I am Mandy Estes. I have gotten a chance to meet some of you lovely nurses out there when I visit, and the best part of my job is meeting new people and getting to “visit” as we like to say here in south Louisiana. I have worked in homecare for a while now for a LARGE company and a small company and now I am blessed to be employed at Haydel Consulting. Can I say I love my job? Who wouldn’t love their job, if it sometimes consisted of writing a blog about the results of a Medicare 101 quiz? Regulations and tests make me giddy.

Throughout my home health career I have familiarized myself with state minimum standards, but I had not sat down and actually read the federal guidelines from front to back until recently. If you haven’t either, you should at least get started. Below is a link to them, it contains very valuable information and will only make your agency more successful. So, let’s get back to the subject at hand.

Observation and assessment. I want to call it the ugly step-sister to teaching and training.  Overuse of observation and assessment is like sending and engraved invitation to Medicare that reads,  “Hey, Medicare send the contractor to look at my charts!”

I don’t think anyone was too sure what to do with question 46, because the guidelines are somewhat vague when it comes to continued observation and assessment after the golden 3 week time frame. I could quote the guidelines verbatim but I don’t want to bore you all so much that you unsubscribe to Julianne’s funny and informative blog on my first attempt.

In a nutshell, the guidelines say this is justified as a skill when there is a risk for complication or exacerbation, but in addition the nurse is evaluating for modifications in the treatment plan. This means they actually want us to do something about the problems we are observing and assessing, not just stand around and write a detailed nurse’s note of our findings. We have all done it; even me.

Make a plan then take action by writing a case conference or calling the doctor’s office. In order to meet criteria, the plan of care must change.

The guidelines specifically address that a longstanding pattern of watching and waiting is not reasonable and necessary.

Let’s all make a pact to read section 40.1 of the federal guidelines focused on skilled services. If you will learn something you didn’t already know and maybe you can share it with the rest of us.  Experience tells that if one person missed something, chances are a lot of people did.   Education is a powerful tool and in our industry education is a must! Stay tuned, there is more to come.

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