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Posts tagged ‘Medicare’

UPIC


I admit that I was a little hopeful, if not disillusioned, when the new UPICs came to my attention.  After verifying that UPIC was not a ZPIC with a typo, I thought that maybe this was a special type of audit where you got to pick the charts you wanted to be reviewed like some people pick their own lottery numbers.  No such luck, I’m afraid.

UPICs are Unified Program Integrity Contractors.  UPICs will carry out program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching[i].  The primary objective of the UPIC is to identify fraud and abuse and make appropriate referrals.  Other agencies recoup overpayment and address recommendations to law enforcement addressing criminal or civil charges.  They can also recommend suspension of payment.  Whether or not the agency is notified in advance of the payment suspension depends on if the UPIC thinks it is possible that the provider will change it’s billing habits if it knows that payment will stop.  Think about that for a minute.  Who wouldn’t change their billing habits if they knew payment was coming to an abrupt halt?

UPICs, like ZPICs can request clinical records, verification of licensure, copies of claims, etc.  The most recent UPIC request I read included a host of new horrors that may not be available and/or are too cumbersome to send.   Here’s a short recap of some of the new things but remember, they can always ask for more or even go to your office to visit.

  1. Copy of the face sheet. I have never used this term in home health or hospice, but it is basically patient demographics and insurance information.  People who have experience in a hospital are likely familiar with this term.
  2. Copy of Medicare card and state identification card (driver’s license or state ID). The logistics of getting a copy of the Medicare card and state identification card involve too many opportunities for loss and theft that I don’t recommend it even if Medicare wants it.  However, Medicare and other payor sources lose money daily when somebody loans (rents) their Medicare/Medicaid card to someone else.  Some software systems allow you to post a picture of the patient on the face sheet.  DNA and fingerprints are not necessary, but the end of the earth is not too far to go if there are any doubts. 
  3. Authorization of benefits. This is almost universally included in the consent form given to patients.  Take a quick look and ensure that somewhere on the consent it says that the patient or representative authorizes the agency to bill Medicare for services.  It would hurt a lot if this statement was inadvertently omitted when all those changes were made to the form relative to the new Conditions of Participation.
  4. EHR Audit Trails. In most systems, these audit trails are cumbersome to obtain and require someone to print or save the audit trail for each individual document.  In one system, the audit trail can be over 100 pages for a single document.  For a long time, there was a vendor who provided audit trails on request, but the agencies were not able to run them.  If you get a UPIC, consider the burden to your agency and call the person who signed your UPIC letter.  It kind of makes paper charts seem appealing again.
  5. OASIS to include the start of care, the resumption of care certification prior to and after the dates of services noted in this request and the discharge. I’m not entirely sure what this means.  To the best of my knowledge, patients aren’t certified after Resumption of Care unless the patient was in the hospital at the end of the episode and there is no change between the recertification assessment (not mentioned) and the ROC HIPPS code.  If an agency has a reasonable hospitalization rate, this is a rare occurrence.  Plus, there are numerous other bullets in the list that mention OASIS assessments.
  6. Travel Logs. Some agencies don’t have travel logs.  Some don’t pay mileage and others pay a flat ‘trip fee’.  I would think a visit log would be more useful to the UPIC but in the two page request, that wasn’t mentioned.

There are many more entries in the UPIC request but even though the length of the list is daunting, it is repetitive.  Laboratory results are requested on page one and all diagnostic tests are requested on page two.  There are individual entries for all hospital documentation, Inpatient records, Inpatient records to support start of care, inpatient records for hospitalizations during the episode, emergency room visit notes and the history and physical.  The best advice I can give is to be careful when delegating the tasks on the list, so you don’t have multiple employees all printing OASIS assessments.

The good new is that most of you will not find yourself in the undesirable position of being the target of a UPIC. If you are one of the unlucky ones, well, it’s not luck that brought you the unwanted attention from a UPIC.  The data analytics are very sophisticated and there is nothing random about the selection of charts (which makes me wonder why a copy of your Medicare Census is included in the list of documents required from the agency.  They know who your patients are.)

That doesn’t mean that your agency is operating outside of coverage guidelines.  It does mean that cloned notes, poor coding, lack of OASIS skills and care plans that are copied from one episode to the next will be under the spotlight.  This results in paying money back to Medicare and additional scrutiny which may extend to your referring physicians who might then begin referring patients to your competitors because they don’t like attention from Medicare any more than the rest of you do.  I do not like it when care is provided to eligible beneficiaries gets denied because a nurse is a little too eager to show off his or her new cut and paste skills.  It’s not like the agency can recoup their paychecks.

Questions?  Comments?  Do you have any experience with UPICs?  Post your comments below or email us.  We need to know now so we can understand them before they become obsolete.

[i] From Noridian Healthcare Solutions

More Conditions of Participation


484.55 Condition of participation: Comprehensive assessment of patients.

Most agencies will not find it difficult to comply with the requirements in the Comprehensive Assessment because they are already assessing these areas.  The fact that ‘Cognitive Status’ which is already included in the OASIS data set and ‘Patient Goals’ are now mentioned in the Conditions of Participation may be an indicator of exactly how serious Medicare is about changing their focus to a patient centered approach to care and outcomes as opposed to the more punitive approach of hunting for agencies that disregard regulations.

The biggest change regarding the Initial Assessment that I see is that the Occupational Therapist is now able to complete the initial visit if OT is the only service ordered by the MD and if the need for OT establishes Medicare Eligibility.  Welcome to the world of Admits, OT’s.

Content of Comprehensive Assessment

  • Current health; functional and cognitive status
  • strengths, goals and care preferences
  • Continuing need for home care
  • Review of all medications (Identify potential adverse reactions, ineffective drug therapy, side effects, significant drug reactions, duplication and noncompliance with meds.
  • Patients primary caregiver and other available support
    • Willingness to provide care
    • Availability and schedules
    • Patients representative if any
  • Incorporation of OASIS data

Recertification visits are still done within the same time frame (days 56 through 60 of episode).  Resumption of care visits are done within 48 hours of the patient’s return to home OR on physician ordered ROC date.

Plan of Care

Patients are accepted for treatment on the reasonable expectation that the agency can meet medical, nursing, rehab and social needs in the home.  Care plan must specify the care and services to meet specific needs identified in the comprehensive assessment.

Plan of Care contents

  • All pertinent diagnoses
  • Mental, psychosocial and cognitive status
  • Types of services, supplies and equipment required
  • Frequency and duration of visits to be made
  • Prognosis
  • Rehab potential
  • Functional limitations
  • Activities permitted
  • Nutritional requirements
  • All Medications and Treatments
  • Safety Measures
  • Risk for Emergency dept visits and rehospitalizations
  • Measures to mitigate risk of above
  • Patient and caregiver education
  • Specific interventions and education
  • Measurable outcomes and goals mutually identified by the patient and agency
  • Advance directives
  • All orders

Each patient must receive a copy of their plan of care.

Additionally, each patient is to receive written instructions that include:

  • Visit schedule
  • Med list with names, dosages and any meds to be administered by agency
  • Any treatments including those administered by agency or persons acting on behalf of agency including therapy.
  • Any other pertinent instructions specific to the patient’s care needs
  • Name and contact information of the agency clinical manager.

Revision of POC

There is nothing new here but something has been removed.  There is no requirement that a 60 day summary be sent to the physician.  It shouldn’t be needed if agencies abide by the following.

  • The plan of care must be reviewed and revised by the physician responsible for the home health plan of care at least every 60 days .
  • Agency MUST promptly alert relevant physicians to any changes in the patient condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered.
  • Revised plan must reflect current information from updated OASIS and contain information about progress to goals.
  • Revisions must be communicated to the patient, representative (if any), caregiver and all physicians issuing orders for the plan of care.
  • Revisions related to discharge planning must be communicated with all of the above plus the patient’s primary care practitioner or other healthcare professional who be providing care for the patient in the community.

Conformance with MD Orders

  • Drugs, services and treatments are administered only upon the order of a physician.
  • Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after assessing for contraindications.

Actions:

  • Review the way your agency handles plans of care and ensure your process includes a mechanism for dissemination of information to all physicians writing orders for a patient.  Review or develop a vaccine policy that allows for administration of flu and pneumonia vaccines according to a well-written protocol developed in conjunction with a physician.
  • Most agencies will have to expand the collection of information related to caregivers and availability.
  • Begin now to audit admissions for the requirements set forth in the CoPs.
  • Begin reviewing admissions using a tool based on the new requirements.  admission-review-tool.pdf  Modify to fit the needs of your agency.
  • Educate your staff.

More Later.  And to think, we haven’t even looked at Quality Assurance, yet.

Care for the (whole) Person with Diabetes


A couple of months ago, I contacted Palmetto GBA about the LCD requiring agencies to obtain Hemoglobin A1C’s on diabetic patients every 90 to 120 days.  Included were the ADA guidelines as well as a Medscape continuing education offering that spoke to the dangers of over-testing.  Palmetto agreed to reconsider the current Local Coverage Determination and today, a response was received from Dr. Harry Feliciano MD, MPH – Senior Medical Director of Palmetto GBA.

It seems that Dr. Feliciano read the information I sent and additional research concerning the prevalence of hospitalizations related to hypoglycemia.  He pointed out that the research I sent excluded diabetics who were on insulin and agreed that the current LCD should be updated.

As such, we can expect some changes in late April to be effective in early May regarding Palmetto’s policy regarding A1C’s.  Based on information from Dr. Feliciano, I would expect to see:

Testing reduced to twice yearly for stable diabetic patients who have met their treatment goals. 

Physicians may adjust treatment goals to lessen the risk of hypoglycemia.

Patients receiving insulin will continue to have quarterly A1C testing.

Patients who have their diabetic therapy changed or are not meeting treatment goals should have quarterly A1C’s monitored.

The purpose of requesting a reconsideration was to lessen the risk of denial for patients who are provided care by your agency.  I am not going to insult you by reminding you that you still have to give appropriate care to patients with diabetes.  You already do that, even when documentation is lacking.  But is it enough?  I ask because the incidence of diabetes keeps climbing and the costs are staggering – 245B per year.  If you do the math, 245B is roughly equal to a whole lot of misery for millions of people.  Maybe its time we up our game.

For very good reasons, the OASIS data set and Home Health compare put a premium on diabetic foot care but there is more to good diabetic care than looking at feet.  The following is from the ADA guidelines regarding diabetes and older adults.

Recommendations[1]

  1. Consider the assessment of medical, functional, mental, and social geriatric domains for diabetes management in older adults to provide a framework to determine targets and therapeutic approaches. E
  2. Screening for geriatric syndromes may be appropriate in older adults experiencing limitations in their basic and instrumental activities of daily living, as they may affect diabetes self-management. E
  3. Older adults (>65 years of age) with diabetes should be considered a high priority population for depression screening and treatment. B
  4. Hypoglycemia should be avoided in older adults with diabetes. It should be screened for and managed by adjusting glycemic targets and pharmacological interventions. B
  5. Older adults who are functional and cognitively intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults. E
  6. Glycemic goals for some older adults might reasonably be relaxed, using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients. E
  7. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment. E
  8. Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. E
  9. When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. E
  10. Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes. E
  11. Patients with diabetes residing in long-term care facilities need careful assessment to establish a glycemic goal and to make appropriate choices of glucose lowering agents based on their clinical and functional status. E
  12. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. E

How many of you ensure that your patients have annual eye exams?  How well and how often do you screen for depression?  Do you run through the PH2 on the OASIS or do you stop and consider each answer carefully in both what is reported to you and what is revealed by other factors?  When was the last time diabetic training for staff was offered at your agency?  If you are visiting a hospice patient, have you adjusted the diabetic regime to provide for comfort as opposed to tight glucose control?

Clinical Record Review

Here are some of the things I see when reviewing records.

  • A patient is taught to drink juice and have a snack when experiencing hypoglycemia.  The same patient is dependent on a walker, has vision loss, moderate to severe pain and is occasionally confused.   Documentation is absent any provisions made for a patient who cannot stroll to the fridge and pour some juice.
  • A patient has a CBG barely over the reporting parameters and the nurse explains it by reporting the patient just ate and took insulin late.  No MD notification. If you think that’s okay, look at the upper parameter.  If it is 150, you might get a pass on patient care but it’s probably double that.  More importantly, surveyors take exception to nurses not following orders.
  • Teaching that complications of diabetes include heart disease, stroke and renal failure to a patient who is on dialysis and suffered a stroke in the post op period following bypass surgery.
  • Patients are scolded when they are discovered eating something that will likely raise their blood sugar such as a donut or jam.  Manners, please.  These patients are our elders and they deserve respect.  Nobody was ever embarrassed to the extent their A1C dropped to below 7.
  • Generic teaching of medications that have very specific and unique side effects.

So maybe the greatest benefit of a relaxed LCD for diabetes is that we can focus our resources on overall better care.  The lowered frequency of A1Cs only applies to stable diabetics with no changes to their treatment but these patients also need eye exams, assessment for depression and emergency teaching for hypoglycemia.  Even if they have been a diabetic for ten years and have been stable for almost as long, make sure they know which medications might cause lactic acidosis and to notify the agency when their activity changes to prevent hypoglycemia.  If you believe that the physician is overly optimistic about your patient’s diabetic goals based on your assessment of the patient in their home environment, respectfully bring it to their attention.

All of these interventions take very little time and can easily be included in care plans when the primary diagnosis is something else.   If we don’t take advantage of ensuring that diabetes is addressed completely when it is not a crisis, the costs – both human and economic – to treat complications will be significantly higher.

To help you get started, her are some resources that may help in developing skills required to assess and treat diabetes.  Please take the time to read one or two and if you find anything that helps your patient care, please share.

Resources for Diabetes

2016 Diabetes Guidelines

2016 Guidelines for Mobile

Lower Extremity Amputation Prevention (LEAP) program

Depression and Diabetes

Coping with Diabetes in Adults

Treatment of Diabetic Ulcers

Diabetic Retinopathy from National Eye Institute

Kidney Disease of Diabetes

Neuropathies in Diabetes

[1] American Diabetes Association. Older adults. Sec. 10. In Standards of Medical Care in Diabetesd2016. Diabetes Care 2016;39(Suppl. 1):S81–S85

Patient Dissatisfaction

What do HHCAHPS surveys really mean? Are they useful in home health and hospice? Read yet another controversial viewpoint from Haydel Consulting Services.

Read more

Giving Thanks


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Wow.  What a challenge.  Thanksgiving is this week and it is only proper that I share with you all the ways we should be thankful.  I’m really struggling.

I could be grateful because I am appealing.  I spend most days at my computer appealing denials for clients.  I enjoy a good argument but the craziness of all these denials for claims for reasonable and necessary care given to eligible patients is overwhelming.  Worse than the financial hit is the overall disrespect of home health and hospice agencies.  If anyone wants to feel like a criminal, all they have to do is work for a home health or hospice. So I may be appealing but I am not grateful.  I would much rather be teaching and doing something – anything – that worked towards better care of patients.  Keep that in mind if you need an inservice or two.

I could be grateful that the Face-to-Face documentation burden has been lightened but I am not.  I guess I’d rather it be lightened than not but I just got ten or so denials this morning related to the requirement.  The Medicare Contractors are going to suck dry the opportunity to withhold money from my clients – and you, too if you do not happen t be a client– until the very last minute.  The regulations taking effect in January have no effect on past denials. 

I could be grateful that more Americans than ever will be able to afford insurance with the ACA but I am not.  The law is so complicated that I think there are only a handful of people who fully understand it and they are not elected officials.  Since nobody really understands it, it has become a dividing line between democrats and republicans who are voting with their party with no idea of how it will play out.  So, no, thank you.  I am not grateful for the ACA.

This doesn’t mean I am not grateful though – even at work.  Home health and hospice have been taken on a ride these past couple of years and you survived. 

I am so very thankful that I know people who are willing to get up and drive to a stranger’s house to adjust pain medications at 3:00 am. 

I know the houses where the water gets cut off for lack of payment located next to the crack house and you find it in you to smile warmly at the patient and show them the same respect that you would if you saw a patient at a $20M Manhattan apartment.

I know your kids are left without a parent during a special football game or school play because you cannot leave a patient in need but I am grateful for the lessen you are teaching to the next generation.  Taking care of others is an important job.  Compassion is a value that should be passed along to the next generation.

I am thankful for those of you who contribute to this blog and The Coders’; even when I don’t agree with you.  I appreciate that you have ideas you are willing to call your own and speak up about them.  You are prime material for patient advocacy.  I like that. 

I love the laughs, the occasional tears and how you make me feel as though I am one of you.  Because I am.

Thank you.

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