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.
Posts tagged ‘Medicare’
Apr 19
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Nov 24
Giving Thanks
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.
Nov 2
Change on the Horizon
The 2015 update to Home Health PPS is considerable and provides for major and minor changes, plus a lot of interesting information. Here’s the bullet points.
Reduction in Payment
No news here. Everyone was expecting a decrease in payment. It comes to approximately $81.00 subtracted from the standard episode rate. The standard episode rate is that dollar amount which is adjusted by OASIS and other factors to find the final payment rate. In contrast, the per visit rate has gone up slightly.
Face to Face documentation requirements
A face-to-face document is still required but the narrative section has been removed effective January 1, 2015. Within the regulations the effect of the Face-to-Face requirement has been described as follows:
- The error rate for home health claims was calculated to be 17.5 percent.
- The majority of home health improper payments were due to “insufficient
documentation” errors. “Insufficient documentation” errors occur when the medical documentation submitted is inadequate to support payment for the services billed or when a specific documentation element that is required (as described above) is missing. Most “insufficient documentation” errors for home health occurred when the narrative portion of the face-to-face encounter documentation did not sufficiently describe how the clinical findings from the encounter supported the beneficiary’s homebound status and need for skilled services, as
required by §424.22(a)(1)(v).
- CMS-1611-F Page 37
Important: All episodes beginning with an OASIS Start of Care assessment will require Face-to-Face documentation. While the risk of denial related to the narrative has been reduced, agencies will have far more opportunities to make an error. This includes patients who return to service after being discharged and patients who were in the hospital over day 60 of an episode and must be readmitted for purposes of billing.
MD/hospital documentation: The regulations state that if requested, an agency must cough up the hospital’s documentation if the patient was admitted directly from the hospital or the physician’s notes that demonstrates eligibility. This should be happening already but from reading clinical records, it is obvious that often the nurses caring for the patient are not reading the hospital documentation. Do not wait until 2015 to add getting the MD records in the chart prior to billing.
Interesting and Important: I think the following excerpt is saying that if agencies provide the physician with the information to support eligibility, the physician may use it if he or she signs off on it. This is in stark contrast to not being able to help the physician compose the narrative. Read for yourself and feel free offer your own opinion.
The initial assessment visit must be done to determine the immediate care and support needs of the patient and to determine eligibility for the Medicare home health benefit, including homebound status. The Medicare CoPs, at §484.55(b), require a comprehensive assessment to be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care, and for eligibility for the Medicare home health benefit to be determined, including homebound status. We would expect that the findings
from initial assessment and/or comprehensive assessment of the patient would be communicated to the certifying physician.The certifying physician can incorporate this information into his/her
medical record for the patient and use it to develop the plan of care and to support his/her certification of patient eligibility. The certifying physician must review and sign off on anything incorporated it into his or her medical record for the patient that is used to substantiate the certification/re-certification of patient eligibility for the home health benefit.
End in Sight
Twice in the Federal Regs, there is a directive that all patients whose care extends into a second episode, must be recertified with a documented estimated end in sight for skilled care. I really thought I missed something in the proposed regs but Lisa Selman-Holman did not see it, either. Regardless of who saw what, the directive is in place. Be careful of ‘statutory’ reasons for denial. This has the potential to be like dates, signatures, etc. Once it is identified that a recertification did not meet requirements, a full denial can be issued.
Math
There are some changes to the payment calculations. I am hoping that someone with a better head for math than myself with go through all the numbers and explain to us the difference. Consider that a cry for help.
Data Submission
There has always been a provision in the Prospective Payment System for a 2 percent penalty for those agencies that did not submit OASIS data. Nobody knew what that meant. Did it mean penalties for no data submission or less than 100% data submission? It has finally been clarified for agencies as 70% of qualifying episodes in 2015 with gradual increases over the next several years.
Since it is now a requirement for payment that the OASIS data used to determine payment be in the state repository prior to billing, this new definition strikes us as ‘late’ for lack of a better word. If you are not sure of your data submission status, call us now. You need help.
Value Based Purchasing
Value Based Purchasing is recycled Pay-for-Performance. The actual indicators that will factor into any payment adjustments have yet to be determined which was common theme in the P4P predecessor. Although this is not our first rodeo with the concept of Value Based Purchasing, this one may stick. Keep your ears to the ground for more information.
These regulations run through 259 pages but like most, there is a lot of fluff and stuff inserted between the good stuff. Take some time and read through the comments and look at some of the data. We will be doing so as well and posting anything interesting or important we find.
Good luck. It’s always an adventure when the regulations are changed.
Oct 28
Taking Care of Numbers
Medicare is talking once again about value based purchasing in home health. This is another name for pay-for-performance which was all the rage ten or so years ago and later, fell off the radar. Basically, Medicare wants to increase payment to providers for being good providers and reduce payment to ‘bad’ providers. Tonight’s post is about just one of many reasons why I do not like Paying for performance or outcomes. Read between the lines and see if you can imagine home health and hospice providers chasing numbers when value based purchasing comes around.
My mother had a heart attack several years ago. My father, an engineer and manager by education called me that Mama was having chest pain but that when he took her blood pressure it was fine. I told him to take her to the hospital. He proceeded to tell me that her blood pressure on the other arm was quite different. A significant difference in readings between the two arms is characteristic of an aortic aneurysm so I told him even more emphatically to take her to the hospital. He insisted on giving me the actual readings which were off by four millimeters of mercury easing my mind about aneurysms and such but I had not had any coffee so I hung up and after telling him I would see him at the hospital.
At the hospital, he asked me what MI was. Mama had just been taken in the back and there was no credible information that she suffered an MI. After a detailed explanation, he asked why they put it on the form between first name and last name. Still no coffee. This was going to be a long morning. Daddy can’t hear very well and in his anxious state, I hated to leave him in search of caffeine.
I spent many years working in a cath lab. Even looking at the clock, the number of minutes seemed excessive although not as excessive as the number of hours it felt like waiting. Finally, the doctor called me back and showed me the films.
Nothing. All I saw was wide open vessels. Mind you, I’m good at this. I can spot a diseased vessel that most people miss. I did not see anything.
He repeated the films several times and challenged me, ‘You still don’t see it, do you?’ Grinning like the winner of an Easter egg hunt who found the golden egg, he showed me the culprit. The tiniest branch of a branch of a branch at the apex of her heart originating at the right coronary artery was occluded. He explained he couldn’t find it either which accounted for the delay. He had to review the films and reshoot a couple of times to be certain. Even with coffee and even if I had seen it, I might have written it off to a flaw in the images.
I was relieved. Mama felt stupid as though she should have known that it was insignificant and Daddy continued to wax eloquently about the variable blood pressure readings. All was well except my son was very angry that we forgot to tell him that his favorite person in the world had a heart attack.
A couple of days later, Daddy called to say Mama was tired and cranky and not able to do her stuff at church. I went to see what was up and found that she had been placed on a beta blocker, aspirin and a statin drug because it was hospital protocol for anyone with a diagnosis of MI. Mama is petite on good days and just short on other days and 25 mg of Lopressor was taking it’s toll on her. She was fine after she stopped it.
She did not need any of the three. Her drug of choice for pain is old fashioned Bufferin. I have almost had to admit her to detox for it any number of times. Her cholesterol is within normal limits and her coronary vasculature was award winning. She exercises regularly and eats so well, I imagine there is an ICD-9 code for her self-imposed dietary restrictions.
Meanwhile, the hospital’s outcomes are keeping up with the Jones’s. In the wisdom of evidence based practice my mother was prescribed three meds that would do her no good. Granted, they were cheap and if I had to choose, I would prefer a global policy of prescribing them for everyone rather than miss a few who needed the medications.
I don’t have to choose as it turns out. Medicare has already determined what pretty much every heart attack patient in the country needs. With all of the critical thinking required to open a refrigerator door, our physicians order medications for all patients according to pre-printed recipe. The hospitals and the physicians with privileges at the hospitals are chasing numbers instead of taking care of individual patients.
What bothers me the most about treating the numbers is that although minor, there are side-effects to the medications prescribed to my mother as she was discharged from the hospital. There was a potential for dizziness and orthostatic hypotension resulting in a fall from the beta blocker. There are side effects of statins including memory loss. An aspirin a day shouldn’t hurt anyone but nobody stopped to ask Mama what she ordinarily took for pain and too much aspirin can cause problems as well. The chances of side effects for Mama outweighed the benefits of treatment.
Treating the hospital’s outcomes should never be mistaken for quality care of individuals. This is something we need to remember when our reported data is being evaluated for purposes of payment.
Jul 2
Face-to-Face Changes?
Many thanks to Tom Calhoun of Bayou Home Care for forwarding me the CMS update regarding proposed Medicare changes to the PPS system while I was out and about yesterday afternoon. (Be sure to click on the link and watch the video on Bayou Home Care’s page. You will understand why I am proud to be known a swamp rat).
Like everyone, I was excited to see CMS start to back off on the unclear, ambiguous and cumbersome requirements of the Face-to-Face requirement. The proposed changes are as follows:
- Eliminate the narrative requirement but the certifying physician would still have to document that a Face-to-Face visit occurred and include the date of the visit. Since nobody can agree on the definition of a ‘narrative’, this is probably a good thing.
- Medicare proposes the consideration of records from the certifying physician or discharge facility ONLY when determining eligibility.
- Physicians billing for certification/recertification for home health services will be denied if a patient is found to be ineligible.
The requirement that only the physician or discharge facility will mean that we can no longer turn to specialists records or pharmacy and other providers of care to support arguments of eligibility or homebound status. I’m not too worried but be very aware of this in the future should these changes come into law.
If you are interested in what your physicians bill for home health certification, check out Propublica’s Treatment Tracker and find your docs. Most do not bill often enough for certification/recertification visits to suffer appreciably from this requirement but some do.
All of this sounds really good, huh? It is – if you are an agency who has never been denied for providing good care to an eligible patient due to a poorly constructed Face-to-Face document.
Word of Caution
I tend to be overly sentimental and my first response to this update was an outpouring of warm feelings towards Medicare. Luckily, I forgot to post this last night and have had time to reconsider my emotional response.
The proposed regulations by Medicare, should they go into effect, will not address any denials that occurred prior to the changes. Recently, Palmetto sent a memo to y’all reminding you that no matter when a patient was admitted, the Face-to-Face documentation must be included with an ADR.
In other words, these changes offer no avenue of relief for denials that have occurred in the past. It also allows for limited denials related to the Face-to-Face document in the future if the start of care date occurred prior to the proposed changes.
The lawsuit filed by Bill Dombi, for NACH – your association – takes the position that the regulations written to satisfy the Face-to-Face requirement were never legal. If NAHC prevails in the lawsuit, then agencies may have recourse for prior denials if all other criteria were met.
I emailed Bill Dombi to determine if I was understanding this correctly and his response was that I appeared to be correct. That’s about all you will ever get from a lawyer without depositions, cataloged evidence, sworn statements and DNA – the appearance of being correct. In this case appearance does count.
So, welcome the changes. Rest comfortably knowing that there is a little gang in congress who are willing to relax the requirements implemented by the Grammar Police. This is a start – not the finish to the remediation of an unwarranted attack on home care for grammatical errors.
Under no circumstances, should you become complacent. The denials that occurred in the past were unfair and new rules taking effect at a future date will not change that. Similarly, don’t overlook the significance of the proposed regulations as it is appears that someone in Washington is listening.
Again, Thanks to Tom and to Mr. Dombi for taking time out of their days to keep me informed.
