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Posts tagged ‘Medicare denials’

Above is a very basic quiz on home health documentation.  It focuses on the type of errors that will result in claims being denied.  Is there a greater insult to a nurse than telling him or her that they do not deserve to be paid after going above and beyond to care for their patients?

Don’t let this happen to you.  Click the ‘Start Quiz’ link and find out how well your documentation measures up.  And call us if your agency might benefit from training from Haydel Consulting Services.


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.


So recently, we have received a ton of emails, phone calls and other signals of distress from clients and others because they are receiving letters from their Recovery Audit Contractor stating that a potential overpayment has been identified via a semi-automatic review.  If the agency agrees with the denial, there is nothing to worry about.  The FI will get in touch with them and arrange for repayment.  If they dispute the information, the agency has 45 days to appeal to their recovery audit contractor. 

I would not have a problem with this except the letters I have seen are threatening to assess and overpayment based upon rules that are not in existence to the best of my knowledge.

Depending on where you live, your letter may be questioning homebound status or OASIS data submission.  In the South, most letters are from Connolly Healthcare regarding OASIS data.

These letters identify an agency’s failure to comply with the Conditions of Participation and earmark the offending claim for denial.  If you get one of these letters, bear in mind the following when writing your appeal:

On January 1, 2010, it became a condition for payment to submit OASIS data prior to billing.  42 CFR 484.210(e) currently reads:

(e) OASIS assessment data and other data that account for the relative resource utilization for different HHA Medicare patient case-mix. An HHA must submit to CMS the OASIS data described at § 484.55(b)(1) and (d)(1) in order for CMS to administer the payment rate methodologies described in §§ 484.215, 484.230 and 484.235.

If you look at § 484.55(b)(1) and (d)(1)  the data described is the comprehensive assessment done at admission and recertification. 

Note that § 484.55(d)(2) is not included in the data required to be submitted.  This refers to the Resumption of Care assessment that does not predicate payment.  For those agencies who are being tentatively denied due to lack of transmission of an ROC.

(Normal people:  what the above says is that you gotta submit the admit or recert oasis prior to billing.)

The payment provision is silent on late assessments.  I strongly encourage you to do everything timely but CMS has forbidden us to discharge and readmit when a recertification assessment is performed late.  CMS offers guidance to agencies in the OASIS Q & A most recently updated in 2009 and current as of January this year with no further reference that I have been able to find.

When an agency does not complete a recertification assessment within the required 5 day window at the end of the certification period, the agency should not discharge and readmit the patient. Rather, the agency should send a clinician to perform the recertification assessment as soon as the oversight is identified. The date assessment completed (M0090) should be reported as the actual date the assessment is completed, with documentation in the clinical record of the circumstances surrounding the late completion. A warning message will result from the non-compliant assessment date, but this will not prevent assessment transmission. No time frame has been set after which it would be too late to complete this late assessment, but the agency is encouraged to make a correction or complete a missed assessment as soon as possible after the oversight is identified. Obviously, this situation should be avoided, as it does demonstrate non-compliance with the comprehensive assessment update standard (of the Conditions of Participation). For the Medicare PPS patient, payment implications may arise from this missed assessment. Any payment implications must be discussed with the agency’s Medicare Administrative Coordinator (MAC).

Because the payment is made by the agencies Medicare Administrator Coordinator (Fiscal Intermediary), it can be assumed that the lack of ADRs from the FI and the fact that the data was submitted timely indicated that no payment ramifications resulted from late assessments.

I know this is all very boring legal mumbo jumbo and I don’t like it any more than you do but thousands of these letters have gone out to agencies.  I have approached Connolly Healthcare, the Recovery Audit Contractor sending out the erroneous edits for OASIS data and they replied with gratitude that I reached out to them and kindly sent me a link to the appeals process.  They were unable to discuss the issues further out of concern for confidentiality.  Note that it has been reported to me that one agency received letters regarding claims for patients at another agency.  Only when I ask questions does their concern for confidentiality appear.

I am not the only one who has reached out to the RACs about what appears to be a faulty program generating semi-automatic reviews tentatively denying agencies based upon rules that do not exist.  I will let others speak for themselves but do not assume that associations created to which you pay membership fees are ignoring this. Call your association if you are a member and ensure that they approach the RACs on your behalf if they have not already done so.

For what it is worth, I know how to write an appeal.  My concern lies in the cost of doing so.  When I write appeals for a client, I bill for it and it is easy to see the cost on my invoice.  When agencies research and write appeals, it costs at least as much but the cost are very difficult to measure.

I am glad I didn’t send the folks at Connolly a Christmas card.  I hate being rude but they are causing a lot of stress and expense to agencies based on bad information.  The respond instructions that you can take valuable time away from your day to address their errors and here’s the part that really threatens to put me in a bad mood:


Please comment or email me if you have received one of these letters. 

Denial Shock

It’s a patently bad idea to share my frustration regarding people who can make or break my career on the internet but after this weekend of working denials, I’ll take my chances.

The first denial I dealt with was the result of a ZPIC audit.  Somebody from AdvanceMed called a patient on the telephone and asked him if he drove. He assured her that he did.  The telephone interviewer, having heard what she wanted without assessing the patient, denied close to 30k in claims.

I actually visited the patient.  I also read his plan of care and medication list and couldn’t help but notice that he was on three or four pain meds that would make it very difficult, indeed, for him to get a driver’s license, but you never know.  The drive to his house included a 15 minute stretch on a country highway, another two miles down a gravel road and then the dirt road.   The trailer itself sat on over  an acre.  He had to climb five stairs to get inside and his scooter which was referenced in the denial was under the carport rusting.  It seems that it is fairly cumbersome to operate a scooter in a mobile home where three adults and three children live. 

But, what sold me on the homebound status, other than his five back surgeries, his lack of a vehicle or a license, his extensive medication list and the challenging physical environment in which he lived was the diagnosis of schizophrenia.  As early as that morning he reported having a conversation with his sister who died tragically two years ago.  He said he usually took Zyprexa and Seroquel but he didn’t that day because he had gone to the doctor to talk about back surgery.

The next denial was for $3,500.00.  It involved a claim with 7 skilled nurse visits, 9 therapy visits and a few home health aide visits.  The reviewer at Advance Med noted that there was no order for the visit to discharge the patient from therapy services.  I went back through the original scanned copy sent to the Zone and found the order.  So what?  Everyone makes mistakes and it was difficult to find.

The claim was not downcoded, you understand, but completely denied.  In full.  

My client appealed to Palmetto who upheld the original denial.  My job this weekend was to explain how the Home Health Prospective payment system worked to entities contracted with our government to monitor the integrity of Medicare payments.  That annoyed me.  I get paid by the hour so maybe I over reacted but I assure you that there are far more useful things I could be doing for clients. 

Lack of therapy orders for another client was the target of yet anther inane denial for a different client.  The client appealed AdvanceMed’s decision to Palmetto who reviewed the two signed orders (the 485 and the physician signed therapy eval and care plan) and agreed that AdvanceMed overlooked both orders.  However, the decision was noted to be ‘unfavorable’ (I love that word) because there was no distinction between short term and long term goals on the plan of care.

They were right.  What can I say?  Who really wants to hear that the entire course of therapy lasted only three weeks?

The most uncomfortable denial I worked this weekend was a claim that was part of a ZPIC request that my company prepared for a client.  They were paper charts pulled from old storage and our job was to put them order, verify signatures and notes, identify any outstanding vulnerabilities, scan 35,000 pages of documents and get them to the Zone on time.  I know you won’t believe this but we, uh, sort of…, well….. we made a mistake.

The claim I was reviewing had orders in it from 2010; a full year after the 2009 denied claim.  I missed it.  AdvanceMed missed it.  Palmetto missed it.  And now its back to me.  I found myself in the awkward position of pointing out that we sent in documentation that implied orders were written in March of one year that were actually written 12 months later.  Not only did Haydel Consulting totally miss the ball on this one but so did AdvanceMed and Palmetto, GBA.  I would like to take this moment to point out that unlike AdvanceMed, I do not have a 105M contract with my client. 

What can you learn from this? 

  1. At least once episode, fully explain the patient’s homebound status.  Being confined to the home due to pain and the need for help to leave the house will do on visit notes but once an episode, put it all together in context in case clinical record is requested for a payment review.
  2. If any claim is requested contains therapy, go buy a red Sharpie and draw a circle around the orders.  Make sure each page of the chart is numbered at the bottom.   Reference the therapy orders by page number in your cover letter.
  3. Include that the patient will win the Nobel Peace Prize prior to his or her death on all therapy care plans.  That way you can google the winners each year and monitor progress towards goals.
  4. The regulations state that all orders must be dated.  Apparently, it doesn’t matter what date you put on the orders as long as they are dated. 
  5. Haydel Consulting Services is not perfect or known for exploiting our warm and friendly relationships with Medicare contractors because we don’t have any.  Hire us anyway because we get results.  Somehow. 

Should I send an invoice to AdvanceMed and Palmetto or let my clients pass on my bill to them?  Maybe CMS could pick up the tab for educating their contractors.

I can’t wait to see what comes up next.  You’ll be the first to know if I am not in jail fighting accusations of healthcare fraud because I sent in orders that were a year late. 

Please keep me posted of any creative new denials you receive.

Company May be on the way….

Lately, some agencies in Mississippi and Louisiana have been entertaining Zone Contractors.  They arrive at an agency and ask for 30 complete claims to be produced that day.  ZPIC activity is not public knowledge so I have no idea exactly how many agencies have been visited but it is substantial.  The ones that have come to my attention total approximately 15 locations with some providers sharing common ownership.

These agencies and the requested episodes are not chosen by mistake or randomly.  The Zone Contractors have been instructed to come up with innovative ways to detect billing patterns suggestive of fraud.  Before they arrive, they know which charts they want to review.   They may or may not visit the patient or the MD prior to their arrival at your agency.  There are rumors that I have been unable to substantiate that some staff members have been followed to determine if patients are visited and how long the employee stayed in the home.

How should you respond if visitors arrive at your office?  Here are my suggestions for what they are worth. 

  1. Do not panic.  They are contracted by Medicare and have every right to be in your agency.  They are there to do their jobs and no amount of attitude will get them to leave.  Be nice.
  2. Ask politely to see identification if they do not offer it right away.  Get the names of the individuals and write them down.  If they do not offer identification, call the Zone contractor for your area and verify that they are supposed to be there.  If you do not know the name of your zone contractor, look it up now and be prepared.
  3. Alert your administrator, your compliance officer and the DON that you have visitors.  Nobody else needs to know.  Quietly ask all unnecessary staff members to exit through the back door but advise them that they are to respond to any calls from the office stat.
  4. A list of episodes will be provided to you.  Assign one or two staff members to collect the documents and bring them to the DON or designee.
  5. The only review that is possible is a review for completeness.  Make sure that all notes are present.  If aide notes are missing, that is bad.  If skilled visits notes are missing do your best to find them.
  6. If you work at one of those agencies that is not above adding a date to legal document after the fact or signing someone else’s name, be aware that I have no use for your agency.  Also be very aware that you do not know what the Zone Contractor has already seen.  
  7. Number the pages and make two exact photocopies at the same time.  That way if something is missing, it is missing from both copies.  
  8. Ensure that senior management is present.  Nothing impresses your payor sources less than an owner or administrator who cannot be found while their agency is under fire.
  9. If you cannot locate visit notes or if upon a cursory review you find that claim should not have been billed (no signed orders or missed visits mistakenly logged as visits), back out the claim and include the paperwork with the information given to the zone.
  10. Do not make small talk with the Zone Contractor.  That pretty much never works out.

You do not have time to complete a clinical record review on 30 charts.  You will have the opportunity to supplement your information in the first two rounds of appeals and most agencies go at least two rounds.  Regardless of the quality of your records, expect a high rate of denials.  Also, expect that nothing will happen fast.

After they leave, go about getting caught up from what amounts to a day of not tending to your business.  Within the next week begin reviewing the photocopies you sent to identify your vulnerabilities.   Start supplementing documentation and gather supporting documents for any arguments you may produce.  When the results finally arrive, you will  be up against a deadline.

If your agency is blatantly fraudulent, get your billing caught up because the Zone can and will suspend payment if they find evidence of blatant fraud.  If your agency is not blatantly fraudulent, expect that within a year you may have your payment temporarily suspended for a few weeks after the second level of appeal and before an Administrative Law Judge.  Stack some bills now and get your creditors paid off in preparation for that time.

Remember, if things get tough, we can help you.  We have more than enough experience in appealing denials.  We have a great record with some clients and a pretty awful record with others.  You can probably guess what the difference is between the two groups.

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