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Posts tagged ‘Medicare’

Apr 13

2 Comments

Compliance is Good Business

In my experience, the greatest barrier to compliance is that it costs money to be compliant.   Compliance plans are cheap compared to turning away referrals that competitors eat up like candy.  Discharging patients when you think you could maybe squeeze one more episode out of them is hard for some people to do.  Marketers working to develop a new referral source are horrified when an admitting nurse turns down a referral because she doesn’t believe they meet Medicare criteria.  There is no doubt about it.  Compliance costs money.

The real question in business is whether or not your investment will show a return.  We all know the businesses who spend far too much money, those that are conservative with their cash and some that are just plain cheap.  The cheap ones will never get it. If you are cheap, you can head on over to Ebay and buy some second hand computers and forget about the rest of this post.  Those that spend far too much money might have already found themselves in a position where their entire operation depends on making use of the gray area which is getting smaller by the minute.  The providers I am talking to are the ones in the middle.  It is hard to get a good provider who has no compliance problems to buy into implementing a compliance plan.  What’s the point?

Here’s the point.

Every day, you sell nursing care and therapy to physicians and other referral sources.  You charge the same amount as your competitor and you cannot offer any discounts, specials or coupons.  You even sell to the same ultimate buyer – Medicare.  You tell the referral source that your agency is the best in the market and that you are trying new and innovative things to keep patients out of the hospital.  You share a donut or a brownie, perhaps and ask about those Cubs even though you hate baseball because you know the referral source loves the Cubs.

Five minutes after you leave, in walks your competitor who says the exact same thing.

Nobody says, ‘Yeah, well we offer mediocre care but we’re no worse than anyone else.’  Even when it’s true nobody says, ‘we suck at what we do but we offer more cash under the table.’  If it really isn’t your day, the doc has a new flat screen delivered to his house or the discharge planner finds a few loose diamonds in the pocket of her scrub jacket after they talk with your competitor.

So, what’s the point of marketing compliance?

Read carefully.  This is important.

You Do Not Sell What You Do.  You Sell Who You Are. 

Is that clear?  The entire healthcare industry has been under what feels like an attack for the past three or so years.  People are running scared.  The FBI is out and about in a big way in the south.  Three physicians in New Orleans involved with a home health agency were raided a couple of weeks ago.  Regardless of the outcome of the FBI raid, no referral source will work with the agency or any of it’s owners/managers again.

Let the FBI be part of your marketing team since they seem to have no desire to go away.  They are not conducting training exercises and there will be casualties.   Work it!

When legitimate referral sources hear about their colleagues getting raided, it does not mean they will no longer have legitimate referrals for ethical home care agencies and hospices.   You need to be ready for their referrals because the providers who are known for their integrity and ethics will be the first ones called.  They are going to choose the one who never breaks the rules, can speak intelligently about the regulations and provide them with substantiated guidance assuring them that what you are asking them to sign meets all known rules and regulations.

Consider the referral you turn away because the patient doesn’t meet hospice guidelines.  Sure your competitor will take it but when you get the chance to explain why you made the decision, a message is delivered that your competitor was operating in reckless disregard of the regulations or maybe just stupidity.  There won’t be too many of those referrals in the future as more docs are having their lives turned upside down because of a relationship with a less than ethical provider.

A compliance plan has other benefits, too.  A soundly implemented compliance plan can distance you from any wrongdoing by a rogue employee.  In other words, if a new hire doesn’t make visits and hands in notes anyway, you can find yourself in a costly situation of returning money to Medicare or you can find yourself arrested.  The deciding factor will be if the employee was working in a culture where effort was made to verify the integrity of the work submitted vs a finding that a rogue employee was part of a culture of fraud.  Ignorance is not an excuse, y’all.  You have an obligation to look for compliance issues.

Compliance Plans

We regularly work with providers who want to establish a culture of compliance.  I find that if the FBI arrives before I do, the motivation is there to do the right thing.  If a compliance plan is just a binder in the corner that looks impressive and compliance training is given with a wink wink nod nod attitude, it is worse than useless.  It can cause more harm to the provider because a reasonable expectation that their employees know how to be compliant has been established and there were no internal audits to identify areas of non-compliance.

We don’t want to work with you if you think implementing compliance looks good in the likely event that you will have company soon.  On the other hand, if you believe like we do that compliance is good business, we can help you.  We feel so strongly about compliance that I’m willing to tell you that a half baked, ugly as home-made compliance plan implemented with full hearted commitment is better than the most expensive and complicated plan ever created that sits on a shelf.

You do not sell what you do.  You sell who you are.

Be the provider that referral sources trust and respect.

Dec 17

5 Comments

New Kids on the Block

 

Strategic Health Solutions is a Medicare Supplemental Review Contractor.  If you haven’t heard of them yet, chances are you will.  They have been ‘encouraging’ agencies to send them clinical records with letters that read as follows:

Effective April 1, 2011 , Section 6407 of the Patient Protection and Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare Home Health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. CMS implemented the face-to-face encounter requirement of the ACA via the Home Health Prospective Payment System (HHPPS) Calendar Year rulemaking. The Final Rule states that documentation of the face-to-face encounter must be present on certifications for patients with starts of care on or after January 1, 2011 .

Office of Inspector General (OIG) work conducted, before the ACA mandate went into effect, found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home health care. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.980(b). Based on this information CMS has directed Strategic to perform postpayment review of Medicare Part A Claims billed for home health services.

As you well know, it is most unlike me to be argumentative but I googled ‘home health referral sources’.  As it turns out, the CDC information from 2010 is in stark contrast to the information provided by the OIG via Strategic Health Solutions.

referral sources

This graph states that providers who only offer home health services have 40 percent of their admissions from a hospital.  It says that 30 percent were from physicians but not that they were the outcome of actual physician visits so lets assume none of them were.  Sadly, the CDC’s 2010 report references 2007 data.

Lets move on to MedPac.  They write reports twice a year for the Congress about how much we are overpaid.  They increase our confusion by writing about how many episodes are preceded by a hospital stay but their data reflects 2010 so that’s a plus.  They say that 27 percent of initial episodes are preceded by a hospital stay and the average length of stay for those patients was 1.4 episodes.  That means that 38 percent of patients come from a hospital.

Neither MedPac or the CDC differentiate between patients  who were in the hospital seen by physicians who did not order their home health and those that did.  If a patient was from out of state, it might be that their personal doctor ordered home health or that a hospitalist saved that special joy for the primary physician.   This is important because it shows how accurate data could potentially be manipulated to paint an inaccurate picture of our industry.

In any event, I can say with confidence that at least 38 percent of patients were seen by a physician because that’s what happens in hospitals.  Doctors come write orders, nurses carry out the orders and the cafeteria always closes five minutes before you can get away to lunch.

So, we have huge discrepancies between the CDC, the OIG/SHS and MedPac.  Who are you going to believe?  My money is on the OIG because the CDC and MedPac do not have the authority to arrest me or monitor my email or phone calls.

So, after that long and rambling trip through the unfamiliar territory of numbers, we are back at the 30 percent mark referenced in the letter reproduced above sent by the OIG/SHS.  That leaves us with some disturbing facts.

We have an entity that looks like a RAC, walks like a RAC and quacks like a RAC but is really a Medicare Supplemental Review Contractor.

The RAC lookalike has noted that in 2010 providers did not adhere to guidance that was effective in 2011.

This non-adherence from 2010 constitutes NEW AND MATERIAL evidence that is being used as grounds to investigate home health care agencies for fraud.

And they will find it.   And it will not in any way, shape or form improve the care that our patients receive.

Note:   Pre-Nursing was the only curriculum that did not require math when I was in college which is why I chose nursing as a career.  Please feel free to correct any mathematical errors – politely, of course.

Jun 13

4 Comments

Battle Scarred

war against fraud

Normally, I try not to be so very outwardly hostile towards CMS but lately, it seems as though the feds don’t really need to justify intruding on my privacy or the bank accounts of legitimate health care providers, so, whatever. The fact is that the face to face document has become the equivalent of a Weapon of Mass Destruction by CMS and their contractors.

You, as a provider, have a lot to lose if you do not honor the provider agreement signed with Medicare.  What everyone forgets is that Medicare signed the very same agreement which guaranteed you payment for rendering skilled care to eligible beneficiaries.

Rightly and wrongly, Palmetto GBA has been denying claims for months with no consideration of the care provided to patients.   This week, CGS announced it planned to follow in the footsteps of PGBA which will radically increase denials for those providers.

The abuse of the Face to Face requirement by CMS contractors has gotten so out of hand that it has become abundantly clear that they are looking for any reason to deny providers regardless of the care that eligible beneficiaries received.

To be clear, there have been agencies who paid a medical director to sign orders blindly for the sake of convenience.  There are other physicians, like Dr. Jacques Roy who sold his signature and his soul for money.  The intent of the document was to ensure that patients were seen by their physicians who were then willing to sign their name to a document stating the patient needed care and was homebound.

So the rationale was sound and initially, it was not much more than an inconvenience for agencies to get an additional document signed upon admission.  Beginning last year, the face to face requirement has been bastardized as a weak excuse to hold onto money that good providers earned providing skilled care to eligible beneficiaries.

There is not a day that goes by that I don’t hear from someone about a denial related to face to face document and more importantly, it is rare that a day goes by that I am not made aware of very real fraud.

I have no idea why Palmetto and CGS have decided to wage a campaign of hostility towards providers.   In the ‘good old days’ when FMR was about the worst thing that could happen to an agency, the solution was simple.  Document well and follow the guidelines.  Lately it doesn’t seem to matter how good or bad your chart is.

One physician wrote in the reason homebound section, the ICD-9 codes for Parkinson’s Disease and scribbled ORIF.  I get that the document did not meet all the requirements for a narrative.  Also included on the document was the patient’s age (85), the fact that he had PEG orders.  Perhaps I am reading too much into the information.  Maybe it is reasonable to believe that an 85 year old patient with Parkinson’s Disease, and a hip replacement could leave the house unattended to play bingo.   Or softball.

Another physician wrote the reason for home health was paralysis.  Skilled nursing was ordered for catheter care and so the claim was denied.  The MD did not realize the nuances of home health coding apparently and the claim was denied because we can’t fix paralysis.

We can’t fix lazy and stupid, either.   It certainly relieves Medicare contractors of the burden of reviewing records if a face to face is not completely accurate or grammatically correct and it has become abundantly clear that many of the records sent are not even read.

The sophistication of the Medicare IT has grown exponentially in recent years.  They are able to tell if the physician who signed the 485 is not listed as the patient’s physician in the database but they cannot see a Part B claim from a physician and determine that the patient was seen timely.  Do they really believe that all those patients admitted from the hospital were not seen by a physician?

Not one single Medicare beneficiary has received better care because of this insane demand on agencies.  In fact, time and resources that could be used to teach nurses about the new Diabetic protocols (bet you didn’t know they were published) or otherwise enhance the clinical skills of nurses are being devoted to getting the physician to document one encounter multiple times to ensure the agency gets paid.  In some cases, the agencies are simply completing the form for the physician’s signature.  They get paid.

I strongly encourage you to play by the rules but also to fight every single denial for a face to face to the level of an ALJ.  The days when the cost of appeal was taken into consideration when determining whether or not to fight it are now part of our rich home health history.  Fight everything until an ALJ or two sees how very abusive these practices are.

Don’t call or email me for a couple of weeks if you have something confidential to say.  I figure after about two weeks, the feds will see how very boring my life is and remove the wire taps. And try to find some time in between ADRs and running down face to face documents to, you know, take care of a patient or two.  Remember them?  Patients?  Elderly, lots of DME and a ton of pill bottles; none of which contain the pill she thinks she takes for sugar.

Please tell us about any face to face horror stories below or email them to me privately.  If you are a client and anyone asks who your consultant is, tell them Jnon Griffin or Lisa Selman Holman.  Just sayin….

Feb 10

5 Comments

The Checkbox Patient

You say the pain feels like an elephant sitting on your chest? I'm sorry but that's not an option. Let's move on.

You say the pain feels like an elephant sitting on your chest? I’m sorry but that’s not an option. Let’s move on.

I get frustrated when I see people try to squeeze an entire person into a series of checkboxes.  This has gotten under my skin for a long time.  Apparently, Medicare agrees with me.  Keep the following paragraph from the Program Integrity Manual in mind when you are shopping for software.

The Program Integrity Manual – the PIM – is the guidance CMS offers to the contractors including RACs, Zone, and MACs. It was updated in December. If you want the full document, google Medicare PIM chapter 3. Chapters 3 and 4 are where I spend a lot of time.  I provided the bold text.

The review contractor shall consider all medical record entries made by physicians and LCMPs. See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation.

The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service. See the Local Coverage Determination for further details.

CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/LCMP may choose any template to assist in documenting medical information.

Some templates provide limited options and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.

Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.

If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met.

So, be wary of programs that do too much for the nurses.  If a program doesn’t require at least a short narrative, it likely will not get done.  If a nurse has scrolled through 50 checkbox questions, said nurse is not going to want to double chart that which has already been documented.

Don’t let some software vendor sell you the moon when what you really need is a clean, consistently reliable system that helps nurses understand and communicate their information.  You need reports and communication.  You need support that can talk to nurses without asking for the System Administrator because usually the Agency and System Administrator and the DON are the same person.

You do not need any more denials.  I assure you.

Jul 18

Data Submission

Have you submitted your OASIS data?  All of it?  Have you looked at your validation reports in great detail to ensure that there was not one fatal error that may have been overlooked?

What about your HHCAHPS data?  Have you been diligent about submitting it?  If your agency had less than 60 patients from March 31 through April 1, have you submitted an exemption request on the HHCAHPS website?

If you are not 100 percent sure about these answers, it might be a really good time to find out and ensure that  you have met your data submission requirements.  You will be penalized if your OASIS and/or HHCAHPS data isn’t submitted.

The penalty sounds modest enough – 2 percent.  But unless you are really good at doing business or really bad at taking care of patients, that 2 percent could be anywhere from 20 to 50 percent of your margin.  If you are really good at taking care of patients and mediocre in the business area, this modest 2% could devastate you.

The Medicare Guidance, which can be found here, reads:

In calendar year 2007 and each subsequent year, if a home health agency does not submit required quality data, their payment rates for the year are reduced by 2 percentage points.

Notice the reference to the year 2007?  The actual reg has been in effect even longer than that and only a couple of agencies here and there were penalized.  The Office of the Inspector General took notice of that earlier in the year and penalties are on the way.  The  Medicare Administrative Contractors (MAC’s – formerly FI’s also known as Palmetto, Pinnacle, etc.) have received these instructions straight from CMS:

Each fall, Medicare contractors with home health workloads will receive a technical direction letter (TDL) which provides a list of HHAs that have not submitted the required OASIS and/or HHCAHPS data during the established timeframes. These Medicare contractors shall review their paid claims history for claims which have:

  • a provider on the (naughty) list
  • Dates of service from July of the previous year
  • Beneficiaries over 18

Here’s the part that is really good:

If the contractor finds any such claims, the contractor shall notify the HHAs that they have been identified as not being in compliance with the requirement of submitting quality data and are scheduled to have Medicare payments to their agency reduced by 2%.

I have yet to see where a threshold for compliance has been set.  It does not say if the majority of data was submitted or if 90 percent of the data was received.

It also doesn’t say how they are going to identify the providers.  Will they look for gaps longer than 3o days between submissions?

My experience is not reassuring.  Agencies have received deficiency notices for late submissions but there have a number of times over the past few years when no data was submitted.  Nothing has been received when no data was submitted.

In one agency, a young lady had indeed submitted the data and placed the validation reports in a binder just as she was told.  Her instructions should have included reading the reports.  Every single assessment had been rejected for a period of six months.

Several times in several different agencies, the person responsible for data submission left employment.  When they did, nobody picked up the relatively insignificant task of transmitting data.

If I were an administrator or a Director, you can prevent disaster by:

  • Requiring OASIS data to be submitted every two weeks.  It is not unheard of that uploading data is difficult and time consuming
  • Require written confirmation that the task was done.
  • If you use outlook, put a recurring reminder with an email that goes out two days before data is to be uploaded.  That way, if you forget about all this a year from now and the person uploading the data leaves, you will get a bounced email
  • Actually look at validation reports and ensure they are being addressed.
  • A system of verifying with your HHCAHPS vendor that submission of data has occurred according to your contract.

If you are a field nurse or someone else who doesn’t deal with OASIS transmission, don’t hesitate to bring a copy of this to the people who do to remind them of the importance of it.  If they are offended, walk it off as my son’s coaches used to say.  I can pretty much guarantee that you will not get a raise next year if your agency takes a 2 percent hit.

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