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Posts tagged ‘medicaid fraud’

Jul 21

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Physical Therapy Goals

The following is from a denial a client sent last week.  The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document.  That denial was overturned in favor of my client but the claim was denied again for a new reason.  You have to see this in order to believe it:

Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.

So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals. 

Did you happen to notice that the entire course of therapy was three weeks? 

Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted?  That really gets under my skin.

In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document.  They agency lost a full round of appeals before the reviewers found something else wrong with the chart.  Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met.  I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal.  In actuality, there were five of these I worked last week.

You have two choices.  First, you can write a short term goal or you can write a very long term goal.   The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged.   I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed.  Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?

An alternative solution would be to write a goal or two for the first visit or first week of therapy.  Some examples that come to mind from who knows where because I am not a therapist are:

  • The patient will agree to participate in their course of therapy by the end of the first visit.  (Chances are this is pretty accurate if the patient allows you in for a second visit).
  • The patient will have all prescriptions for pain filled prior to next visit.  (I do not like the way it sounds when therapists work with un-medicated patients.)
  • The patient will have DME delivered by end of day 4 of episode.  (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.

I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh.  I assure you that is not the case.  All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation.  Be bold about it.  Include page numbers.

I would be interested to hear what is happening in your offices.  Has anyone else seen denials like these?  If so, what contractor?  (Palmetto, NGS, CGS, etc.)  Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below. 

Feb 11

2 Comments

Personal Care Services

Who else do you know that has been assaulted by one personal care attendant and threatened (as recently as an hour ago) by another?  None of this had anything to do with work.  I could tell you stories for days but I want this uploaded to the internet soon in case I unexpectedly die.  I want you to read it so that you can look a little harder at the personal care attendants taking care of your patients.

Let me start by saying that some of the most wonderful caregivers in the world are PCA’s.  They have saved more lives than we’ll ever know simply by alleviating loneliness, keeping our elderly safe in the home and making sure they are properly nourished.  You couldn’t count the number of broken hips, bedsores, falls, infections and accidents they have prevented.  A personal care attendant can prevent nursing home placement which many elderly people fear and become part of the family.  The majority of PCA’s are give more than they take.

There are other personal care attendants and companies who are no more useful to society than your run of the mill crack whore.  Consider the following cases:

  • Numerous indictments have been obtained because personal care assistants continued to bill for patients who had moved out-of-state
  • Countless hours have been billed fraudulently.  Many times, the PCA’s do not meet minimum employment standards.
  • Others continued to bill when patients were in hospitals and nursing homes.
  • A PCA boyfriend billed for providing personal care to his girlfriend while she was in jail.  The girlfriend got mad and turned her boyfriend in when he would not use the fraudulently obtained Medicaid money for bail her out of jail.
  • According to an indictment which has not gone to court yet, a beneficiary got out of jail for a one day furlough to meet with his case worker at home so he could continue receiving Personal Care Services. Allegedly, he was approved for the services and then returned to jail while Medicaid continued to foot the bill.
  • A personal care attendant admitted to forging  a personal check in the amount $10,000.00 from her patient’s personal checking account.  She then deposited it into her mother’s account.  The check did not clear.  This is almost forgivable.  There must be a diagnosis that prevented her from understanding how bank checks worked.
  • A New York provider will be paying back over 2M because they billed for services not rendered and inflated hours on billing.

This paints a pretty bleak picture of the personal care industry.  Keep in mind that there are no OIG press releases about legitimate companies who provide excellent care.

What can you do?

  • If you are discharging your patient to PCS services after skilled care is no longer needed, try to overlap a week or so if your state allows it.  You can spend some time training the PCS on the proper way to care for your patient’s unique needs.
  • If your patient has personal care services established when you admit the patient, check up on them.  In the situations where I have been threatened it was because a friend who was afraid to talk to the aide was eager to talk to me.  Ask direct questions about the quality of care and the level of satisfaction.  Pay attention to both what the patient says and doesn’t say.
  • Ask to view the home folder.  Call the PCS company and speak with the RN responsible for creating and overseeing the plan of care for the home worker.  To coordinate care, there should be a copy of the most recent care plan in the home.
  • Review the home folder for accurate contact and grievance information.  Verify the phone numbers and the name of the owner/Director of Nursing.  Write the number in large print for your patient to see.
  • If you frequently find your patient alone, ask about the home worker’s hours and care plan.  Check the time sheets if they are kept in the home binder.

The OIG looks a lot at the dollars spent on fraudulent visits.  Medicaid costs for personal care services in 2011 totaled $12.7 billion, a thirty five percent increase since 2005. The U.S. Department of Labor projects that the employment of personal assistants and home health care workers will grow by 46 percent by 2018.

We should look more at the care given to our patients.  In most cases, people who are willing to commit fraud are not overly committed to the wellbeing of their patients.  There is no shortage of personal care attendants looking for work and some of them are very competent and dedicated to their patients.

If you’re thinking this is not your job, I beg to differ.  You have a responsibility to ensure that caregivers, paid or unpaid, are responsible and capable.  Remember you are a mandated reporter of abuse and neglect.  Coordination of care is a Condition of Participation for all Medicare Providers.  More importantly, it is one of the underlying principles of sound clinical practice.

The last threatening phone call I got was a little while ago.  If this ends up being the last post I write, it was good knowing you but don’t lose any sleep fretting about me.  I am too stupid to be afraid and that tends to confuse people who mean to harm me.

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