Skip to content

Posts tagged ‘Medicare Reform’

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.


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. 


You In?

I received an email from somebody last week who made the first valid points about The Alliance and associated groups that I have read.  Respectfully I do not agree with most of his points, but it did give me pause to consider some of my positions.  I remain firm on my position that the exclusivity of these groups and the ulterior motive of some members are reprehensible and contemptible.

That was my disclaimer.  Let me share with you one or two of his opinions that hit home.

First of all, CMS is not going to listen to any providers from any sector of the industry ‘whine’ about payment.  That much is certain whether you are the Alliance or Joe Bleaux on the street.  Fair, according to CMS is determined by the numbers.

I took the time to read the trustees report to Medicare over the weekend so you wouldn’t face that burden.  Say, Thank You, Julianne.  Most of the information was fairly useless to us as home health providers.   Some of it was so boring that I came close to tears a couple of times.  But within the report there were one or two things that are important to us as clinicians.

Here are some numbers from the report.  Stay with me.  Your only alternative is to read it yourself.

Medicare Expenditures for 2010 in Billions


Part A Part B Part D Total
Benefits 244.5 209.7 61.7 515.8

By Provider Type

Hospital 136 31.9l 168
Skilled nursing facility 26.9 26.9
Home health care 7.0 12.1 19.1
Physician fee schedule services 64.5 64.5
Private health plans (Part C) 60.7 55.2 115.9
Prescription drugs 61.7 61.7
Other 13.8 46.1 59.9

The report also said:

It is possible that healthcare providers could improve their productivity, reduce wasteful expenditures, and take other steps to keep their cost growth within the bounds imposed by the Medicare price limitations. For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains—a very challenging and uncertain prospect.

The last sentence is worthy of repeating.  “For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains – a very challenging and uncertain prospect.”

For the home health care industry, I think it is challenge we will meet.

The next argument posed by the anonymous emailer is that the researchers and brain power in these groups was very high level.   I will begrudgingly concede that there is room for this kind of academic and intellectual examination of our industry.  But, I am a nurse and I know nurses and we are just as smart, as a whole, as any other group on the planet.  Plus we have an edge.  Nurses answer to a higher authority than any shareholders, state licensing board, policy maker organization, or even Congress.  We answer to the patient first, and then to each other.

So, down to business and I do mean business.  We sell health care for a living.  In particular, we sell nursing care and to a lesser degree, ancillary therapies.  I have used the analogy that home health agencies are like brothels in the past to illustrate that all the payor sources care about is the end product.  I was advised that some people may find my analogy offensive.  I can’t imagine why the sex industry workers would be offended but just to show my sensitive side, I will not expound on my analogy.  The point I was trying to make is that our end product is our clinical care.

In other words, CMS and Medicare HMO groups do not care who has the best accountant or even the most paid lobbyists.  They judge us by how well we perform as determined by our cost vs benefit ratio to the overall Medicare budget.

Looking at the budget numbers, the first thing you see is that the bulk of the budget goes towards hospitalizations.  Over 168 billion dollars last year was paid to hospitals from Medicare alone and I assume approximately equal percentage was paid by the Managed Care Plans in Part C. If we are competent and keep hospital rates down, we will survive.  If we are excellent and reduce overall costs to the Medicare trust, we will be golden.  They will turn to us for answers and be eager to give us the budget to care for patients.

Next number to look at is Physician costs.  Every time we provide appropriate contact to a physician for a patient already on service we reduce the total payment to physicians.  Obviously, physicians are our colleagues and we are not out to eat into their income.  But, I think even the doctors appreciate a nurse who recognizes the need for intervention and arranges for it with his assistance as opposed to interrupting his day with an unplanned patient visit.  If you keep their patient out of the hospital, you have proven your worth to them more than any expensive dinner or cute little sticky notes.

Look at the part D drug expenses.  We like drugs.  Patients like drugs.  Drugs are good things.  Nurses, in particular, are fond of drugs.  How many of you have ever wished for a Xanax or Prozac salt lick in the office.  By making a concerted effort to truly examine our patients’ medications and identify duplicate and ineffective therapy, we both improve care and reduce the risks of hospitalizations.  When we identify medications that are ‘left overs’ from an illness the patient no longer has, we save money.  We don’t do that.  I know it says that we do in the OASIS, but as an industry, there is vast amount of room for improvement.  We do not need policies or pathways to check medications.  We just need to remember to do it and address all inconsistencies.

Nursing home care is expensive.  The part of nursing home care that Medicare pays for is ‘skilled’ needs much like the skills we can and do provide in the home.  Ask yourself; is it better for the patient to be in the home or in a nursing home?   If you can provide those same skills at a lower level of expense than a skilled nursing facility or rehab hospital, you can save the Medicare system money.  Better than saving money is that you may be able to keep the patient in his or her home where life is much friendlier.

So, there is your challenge. You in?

President’s Plan for Health Care Reform

Paying for Health Care Reform

$313 Billion in Additional Savings to Create a Deficit Neutral Plan

We have the most expensive health care system in the world, but do not get the best results. The rising costs of health care are a burden on our families and a drain on our long-term economic growth. If we continue on the course we are on, health care expenditures will reach 20 percent of GDP within a decade. Rapidly rising health care costs are leading our nation down a fiscally unsustainable path.

For the health of the American people and the health of our economy, we must act now to bring down health care costs and reform the health care system. It is central to the long-term prosperity of the United States. That is why the President is committed to passing health care reform this year. Guided by the principle that we should fix what’s broken and build on what already works, the President wants to pass health care reform that allows one to keep their health insurance and choose their health care providers, expands coverage to the millions without, and brings down the cost of coverage.

The President is committed to undertaking reform that is completely paid for and deficit neutral over the next decade. That is why he put forward in his FY 2010 Budget an historic $635 billion down payment on reform. Roughly half of this amount comes from revenue proposals, including limiting the value of itemized deductions for families making over a quarter-million dollars a year to the rates they were during the Reagan years, and about half comes from savings from Medicare and Medicaid.

Since making this proposal, the Administration has worked with Congress on other ways to offset fully the cost of health care reform through additional savings and revenues. To that end, the Administration is detailing today savings proposals that will contribute another $313 billion over 10 years to paying for health care reform, bringing the total scoreable offsets put forward by the Administration to nearly $950 billion over 10 years. Together, this would extend the solvency of Medicare’s Hospital Insurance Trust Fund by seven years to about 2024, and reduce beneficiary premiums for physician and outpatient services by about $43 billion over the next 10 years. The Administration hopes these suggestions will help Congress as it continues to draft legislation, and remains open to any other proposals to pay for reform that Congress may put forward.


Health Care Reserve Fund

($ in billions)

10 years

FY 2010 Budget

–  Medicare and Medicaid Savings

–  Revenues




Additional Medicare and Medicaid Savings

–  Incorporate productivity adjustments into Medicare payment
–  Reduce hospital subsidies for treating the uninsured as
coverage increases

–  Pay better prices for Medicare Part D drugs

–  Other








Reforming the health care system does not end at expanding coverage and making sure that it is paid for; we also must address the underlying problems in our health care system that impede quality improvements and raise costs. The President therefore believes that in addition to scoreable offsets, we must take steps to transform the health care system, such as investing in health care information technology, patient-centered quality research, prevention and wellness, and in creating a system that pays providers for providing better care not just more care. Over time, these steps will help to produce a health care system that works better and costs less.

Paying for Health Care Reform: New Savings

As was emphasized when the President’s Budget was initially released, the reserve fund represents a substantial down payment but is not by itself sufficient to fully fund comprehensive reform. The President has insisted that reform must be deficit-neutral based on real savings and revenue estimates as determined by impartial scorers. Thus, in addition to the proposals included in the FY 2010 Budget, the Administration is putting forward policy options to further rein in federal health spending, make the system more efficient, and deliver better quality of care. When combined with the Budget proposals, these new options would extend the solvency of Medicare’s Hospital Insurance Trust Fund by seven years to about 2024. These new savings include:

  • Incorporate productivity adjustments into Medicare payment updates. Productivity in the U.S. economy has been improving over time. However, most Medicare payments have not been systematically adjusted to reflect these system-wide improvements. We should permanently adjust most annual Medicare payment updates by half of the economy-wide productivity factor estimated by the Bureau of Labor Statistics. This adjustment will encourage greater efficiency in health care provision, while more accurately aligning Medicare payments with provider costs.
  • Reduce subsidies to hospitals for treating the uninsured as coverage increases. Instead of paying hospitals to treat patients without health insurance, we should give people coverage so that they have insurance to begin with. As health reform phases in, the number of uninsured will go down, and we would be able to reduce payments to hospitals for treating those previously uncovered. This would be done by establishing a new mandatory mechanism to better target payments to hospitals for unreimbursed care remaining after coverage increases. Beginning in FY 2013, payments would be gradually phased down so that by 2019, funding would equal 25 percent of Medicare/Medicaid Disproportionate Share Hospitals (DSH) funding in 2013, and updated by inflation.
  • Pay better prices for Medicare Part D drugs. In its meeting with the President and subsequent communication, the pharmaceutical industry has committed itself to helping to control the rate of growth in health care spending. There are a variety of ways to achieve this goal.  For example, drug reimbursement could be reduced for beneficiaries dually eligible for Medicare and Medicaid.  The Administration is working with the Congress to develop the most appropriate policy to achieve these savings.

Other Savings

  • Adjust payment rates for physician imaging services to better reflect actual usage. To provide more accurate payment for physician imaging services, the Department of Health and Human Services would increase the equipment utilization factor for advanced imaging (such as magnetic resonance imaging (MRI) and computed tomography (CT) machines) from 50 percent to 95 percent. This proposal – which is closely aligned with a Medicare Payment Advisory Commission (MedPAC) recommendation – would better reflect how these technologies are actually used.
  • Adopt MedPAC’s recommendations for 2010 payments to skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. To bring down costs and maintain quality, we shouldupdate payments based on MedPAC’s consideration of multiple variables, such as quality, access to care, and adequacy of payment. Doing so would implement MedPAC’s 2010 payment recommendations for skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals.
  • Cut waste, fraud, and abuse. It is important that patients get the best care, not just more care. Unnecessary treatments are not only expensive, but also can harm the health of the patient. To discourage physicians from ordering unnecessary or excessive treatment, we should increase the scrutiny of physicians in high-risk areas or those that order a high volume of high-risk services (such as home health, durable medical equipment, and home infusion therapy) through additional pre-payment review.

Paying for Health Care Reform: 2010 Budget Proposals

The above savings would be in addition to the down payment for comprehensive health care reform of $635 billion over 10 years detailed in the FY 2010 Budget. The reserve fund is financed roughly half through proposals to generate more revenue, and half through efficiencies and savings from Medicare and Medicaid. Based on our projections, the Medicare proposals contained in the reserve fund would extend the solvency date of the Hospital Insurance (HI) Trust Fund by two years and reduce beneficiary premiums for physician and outpatient services by about $33 billion over the next 10 years. As a result of these proposals, Medicare beneficiaries will also see an improvement in the quality of their services. The reserve fund includes a broad array of savings proposals including:

  • Reducing Medicare overpayments to private insurers. The establishment of a competitive system where payments are based upon an average of plans’ bids submitted to Medicare would save taxpayers close to $177 billion over 10 years, as well as reduce Part B premiums.
  • Improving Medicare and Medicaid payment accuracy. By strengthening program integrity efforts, the Centers for Medicare and Medicaid Services (CMS) will address vulnerabilities that have led to billions of dollars in overpayments and fraud each year.
  • Improving care after hospitalizations and reducing readmission rates. A combination of incentive payments and penalties should lead to better care and result in fewer readmissions – saving roughly $25 billion over 10 years.
  • Expanding the Hospital Quality Improvement Program: By linking a portion of Medicare payments for acute in-patient hospital services to hospitals’ performance on specific quality measures, quality of care for beneficiaries will improve, and Medicare will save approximately $12 billion over 10 years.
%d bloggers like this: