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Posts tagged ‘Medicare denials’

Getting Paid Part 2


Do the Right Thing

This isn’t some super moralizing appeal to your conscience to stop forging signatures or lying about visits you didn’t make.  Those kinds of people do not come here for news and information.  This is more of an appeal to nurses and clinicians to follow orders.

In the past several weeks, I have read many instances of nurses charting about why they did not do the right thing.

One of the most frequent excuses for a weight that is out of range and the nurse writes in parentheses that she used a different scale.  What does that tell you?  Here’s what it tells me:

  1. She does not know what the patient should weigh
  2. She has no idea if the patient is better or worse than before
  3. She did NOT follow orders
  4. She may be costing the agency money by setting her employer up for denials

I read a note last week that state the patient’s blood sugar was 370 but the son had only just now given insulin.   There was a note that the patient ate breakfast but no MD notification.  I suspect the patient eats breakfast regularly.  The question is whether or not the son is always able to give insulin timely.  If not, maybe a different kind of insulin would be better for the patient.

I have read may notes where the blood pressure exceeded either the MD parameters or just common safe practices and the nurse charts that the patient hasn’t had their medications yet.

In other words, nurses are spending time explaining away why they did not follow the care plan when they should be notifying the MD.  Maybe the blood pressure is extremely high every morning before medication. It certainly is more convenient if the patient strokes out in the morning but that is not a reason to let a patient’s pressure pound against their arterial walls every morning.

In order to get paid you must do the right thing.  If you do not communicate with the physician and if the care plan does not change, your patient is no longer eligible for services.  Explaining why YOU didn’t follow orders is not a billable skill.

Again, here is the language that I read repeatedly when appealing denials:

The records provided do not support that the skilled nursing services were reasonable and necessary for the treatment of an illness or injury. During the last certification period, there were no exacerbations, injuries or new diagnoses that would require continued skilled services.

Any questions?

Remember, answering to us is a lot more fun than answering to Palmetto or the Zone when you get ADRs.  And if you do get ADRs after reading this, I respectfully reserve the right to say, ‘I told you so’.

Skilled Charting


Our small little company probably sees more denials than anyone else other than say Palmetto or one of the Zone contractors.  So we make a lot of fuss about documentation and getting paid but while we are very good about finding errors, we don’t offer as much as we should in teaching documentation with payment in mind.  I’m not going to bother with that now as I have a lot to do so let me just show some examples of bad, better and really good documentation.

Skilled Teaching – Diet

Bad:  taught low sodium diet.  (worse if this is not the first time)

Better: Taught patient how to read food labels for sodium content.  Used handout attached.

Best: Taught American Heart guidelines for low sodium diet according to handout pages 1 and 2.  Copy attached and left in home folder.

Homebound Status

Bad:  SOB on exertion (everyone gets short winded if they exert themselves enough)

Better:  Patient is short of breath when walking 20 feet.

Best:  Patient is unable to leave the home due to SOB r/t CHF, arthritic pain and impaired judgment due to narcotic medications.  Requires cumbersome assist devices and at least one person to help leave the home.

Diabetes Foot Check

Bad:  Taught patient to perform foot care.

Better:  Inspected all surfaces of feet.  No problems noted.  Patient was able to demonstrate foot care with a mirror.

Best:  Inspected all surfaces of feet while simultaneously instructing patient on foot care and (proper footwear), (risks of decreased sensitivity), (risks of going without shoes), (when to see podiatrist), (importance of annual eye exam).  Take your pick and rotate through the list.

PT/INR

Bad:  PT/INR drawn per orders and brought to lab.

Better:  PT/INR drawn per orders.  Called team leader to watch for results.

Best:  10:00  PT/INR drawn.  Dosage of 5 mg/day Coumadin noted on lab slip.  4:00 pm  MD confirmed receipt of lab.  INR 2.8.  No new orders.

Any0ne else care to add to the list? Yes, you’ll chart a little more but if you blow off the recap of what is on the flow sheet – assessed all body systems, patient awake alert and oriented times 3, denies pain, etc., etc., you may find that you write less and say more. Better yet, you will get paid for your hard work and your outcomes will improve as well.

Difficult Decisions


Be honest with yourself.  Have you ever held on to a patient longer than they technically qualified for home health services because there was nobody else to take care of them?  Have you ever recertified a patient for diabetes because they had an isolated blood sugar of 302 after washing birthday cake down with coke? What about the patient who has achieved stability at rock bottom and the only alternative for the patient is a nursing home?

I can spot patients who do no longer meet Medicare coverage guidelines a mile away because of my superpowers.  Also, I am not emotionally attached to your patients so it is easier for me to be objective.

These are the facts and I do not like them one little bit:

  1. Observation and assessment is a skill for only a short period of time (generally 3 weeks) unless there is documentation to support why the patient remains at increased risk.  This means stuff like actual falls and changes to the plan of care.  Headaches during allergy season that are controlled with Advil do not paint a picture of increased risk.
  2. Teaching is a covered skill.  Re-teaching is only a skill if there is a documented reason why said re-teaching was indicated.  Teaching is NOT a skill when it becomes apparent that the patient cannot or will not learn.  This means that teaching an advanced Alzheimer’s patient new skills will not be deemed reasonable and necessary.  It does not matter how hard you teach someone who is unable to learn.
  3. Homebound status is very poorly defined unless you work for someone with the authority to deny your claims.  Document homebound status.  If the patient meets homebound criteria three ways, document three times.  Everyone is SOB with enough exertion.
  4. There is a space at the lower left corner of each 485 that reads, “Attending physician’s signature and date signed”.  A Nurse Practitioner, physician assistant or love interest of a physician is not a physician.  When you identify actual physicians, try to narrow your choice down to the one who actually attends to the patient’s need and obtain their signature.  A signature is when somebody write their own name in their own handwriting or uses a secure electronic alternative.  Don’t stop yet.  Get the DATE.  If you haven’t heard me rant about dates yet, it is because you haven’t been paying attention.   
  5. Sadly, home health aide services do  not qualify a patient for home health.  In the event that you admit a patient who will likely require services indefinitely, that is the day you should begin searching for an alternative. Call relatives.  Beg churches.  If the patient  has Medicaid, find waived services for the patient.  Anticipate the day you will have to leave your patient alone in the house because there are no more skills to render.

It is heartbreaking to discharge some patients.   Sometimes it helps if another nurse goes to do the dirty work.  I have taken the discharge of patient in need of services not covered by Medicare harder than I ever took a death in all my critical care years.  There’s nothing left to do for a patient at room temperature.  Lonely elderly folks with vital signs are the ones who turn my heart to mush.

Knowing what constitutes skilled care going into the house will guide you in seeking alternatives to what feels like abandoning a patient in need. Remember, the folks who do ADR’s and ZPIC reviews do not know how sweet your patient is.  They have not been seen how happy your patient was to share with you the cookies someone made for them at Christmas.  They have not heard about the way music used to be played when it was good or held your patient’s hand when they lost a spouse.  If you are a good nurse, a patient will touch your life as much as you touch theirs.

But, none of that sappiness, as real as it in our hearts will keep you out of trouble if you do not provide skilled services according to Medicare guidelines.  When you fail to follow guidelines, you put at risk all of your patients, your employees or employers, their families and the agency’s stakeholders.  Better just to start planning your exit strategy on admission, wouldn’t you think?

If you have any questions, please contact us or post below.  If you want to hire Haydel Consulting Services to discharge your lonely patients, we will be glad to do so.  Just take our regular hourly rate and multiply it by 72,761 and plan on a 50 hour minimum for discharge services.

Getting Paid


I see a lot of denials in my job.  Some (actually a lot) are legitimate because the agency hasn’t complied with one or more regulations.  I have also seen an alarming rate of denials that cause me to question the competence of those performing the reviews.

Last week I received a copy of a denial.  It was actually the second denial on the same claim.  Palmetto GBA originally denied the claim as they did not think that the Alzheimer’s patient confined to a wheelchair was homebound.  My client appealed to Maximus who agreed that the patient was in fact, confined to the home but then denied the claim because there was no documentation of the face to face encounter.  The reason my client did not send the documentation is because the episode in question was the second episode and the face to face encounter occurred prior to the first episode.

I am also seeing claims denied because of physician signatures.  In some states, my own included, the signature requirement in the minimum standards reads that if the agency documents when the orders were received by the agency, that will suffice as evidence that orders were received timely according to state minimum standards.

The state does not pay your Medicare Claims.

Medicare requires that the physician both sign and DATE his or her signature.  Failure to do so will result in a denial.

Statutory Denials

Statutory denials are like free spins on the slot machine for the folks who review ADR’s and other claims.  A statutory denial means that the patient was somehow not eligible for services and therefore, nothing is covered.  Compare that to a denial because the reviewer did not think that two of the visits were covered.  If the total number of visits was greater than 6, then the two non-covered visits will not result in a loss to the agency.  If an ICD-9 code is not supported, the payment will be downcoded usually costing the agency a couple of hundred dollars.  But if the patient is not homebound, or there is a problem with the physician, or the orders are not signed, the claim is denied in its entirety and no further effort is required by the person doing the review.

Now, if it were me and y’all can thank your higher power it isn’t, I would go for the statutory denials every time.  (And I could find them, too.)  These are also the easiest to prevent.

Getting Paid

  1. Everyone in the agency should be aware of the signature requirement.  The primary responsibility should lie with the first person who sees the orders whether it is the marketer or the person receiving the mail.  However, nobody should see an undated signature without bringing it to the Director’s attention.
  2. Be obnoxious about dates.  Buy some file folder labels and print, ‘Please sign and DATE your signature’ at the bottom of every order.  Use red ink.  Make it interesting and noticeable.  Add a note about dating signatures to your fax cover sheet used for orders.
  3. Because marketing staff often have more exciting things to discuss, make badges that read:  I need a date.  That will spark some lively conversations.
  4. With every ADR that is submitted to your MAC, include the description of homebound status as found in the Medicare Benefits Manual.
  5. After the patient’s initial episode, ensure that the face to face encounter is included in the summary. That leads me to;
  6. Write a summary.  If your agency is not writing summaries for each episode, begin writing them now. For ADR’s there is nothing wrong about documenting after the fact as long as the documentation is dated on the day that you wrote it.
  7. If you find an egregious error that cannot be ethically corrected, cancel the claim and send documentation along with your ADR.  This won’t affect the outcome but it is the classy thing to do.  It also shows that you do know how to recognize errors.  Please note that some errors can be corrected ethically.  Do not be too hasty in cancelling claims.
  8. If at all possible, have someone who has not been involved with the patient review the documentation you intend to submit.  It is too easy to read between the lines when you know about the patient.  The holes are not glaring to you.  If you have a branch or if there is an another agency owned by the same organization, trade off ADR’s.  If you do not have a sister agency or anyone in your organization, consider using a professional consulting service.  I can recommend a good one if you need one.
  9. Write a cover letter if there are any discrepancies in your documentation.  For instance, you may have a very weak patient who progressed to her highest level of functioning with therapy in a prior episode.  Note this so the chart does not look as though you have a patient in need of therapy but failed to provide it.  (Yes, the reviewer should be able to look at past claims but they should also know homebound status and when the face to face encounter occurs as well.)
  10. Share your ADR results with your staff.  It is so much easier to learn from the errors of others.  Too often, agencies don’t want word to get out on the street that they have received a ton of ADR’s.  Get over it.  ADR’s are being sent out at a rate that might very well save the United States Postal System from financial ruin.

We are always interested in hearing about those strange and somewhat inappropriate denials.   Please share with us if you have one that we might teach us all a little something about getting paid.  After all, it doesn’t matter how much congress reduces the home health payment if you are never paid.

And as always, we are available to help with ADR’s.  We read clinical records as though payment is coming from our own pockets (because it is!) and do our best to get you paid.  Mind you, we can only work with what we are given.  So, write those summaries and get signatures dated.

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