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Posts tagged ‘Medicare’

Jul 8

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Reducing Fraud

Everyone agrees that the industry has had enough of fraud.  In fact, some industry leaders have already declared, ‘Enough is enough!’.  I wholeheartedly concur with that eloquent and emotional pronouncement of the common values of Home Health Providers.  So lets take a look at how we can reduce fraud and cut the home health budget, shall we?

  1. Ensure that nobody gains entry into the Medicare program without undergoing a criminal history background check.
  2. Test all owners and managers according to standards set forth by The Secretary to ensure that all owners and managers understand HIPAA, coverage guidelines, compliance rules, marketing guidelines, etc.
  3. Require providers to put up a 100K surety bond and demonstrate they have the capital to operate.
  4. Mandate compliance programs or if you prefer, ‘Promulgate rules requiring home health agencies to have in operation a compliance and ethics program designed to prevent and detect criminal, civil, and administrative violations’.
  5. Do not issue provider numbers in geographical areas where there is a lot of fraud or where there are a lot of providers.
  6. Put a Cap on Episodes much like IPS.  Urban agencies will be limited to less than two episodes in the aggregate and rural agencies can go up to 3.2.
  7. Penalize agencies who do not bill for LUPA’s.
  8. Have the MACs (FI’s) perform a payment review on  a random sampling of claims in all agencies to make assumptions about the agency based upon OASIS data prior to paying claims to ensure accuracy of claims.  I am available at my hourly rate to assist agencies in this process which resembles RAC audits.
  9. Place all new agencies or agencies that acquire new provider numbers to  them on a 100% percent prepayment review of claims.
  10. Get rid of the therapy thresholds.
  11. Tighten up the face to face encounter time frame so that all patients except those who have just been discharged from the hospital must be seen within 14 days of admission..
  12. Allow Nurse Practitioners to sign plans of care.

It is possible that one or two of you are sitting there wondering how I ever became so brilliant and are willing to stand up and fully support these recommendations.

It is equally possible that some of you think I am knitting with one needle or that my IQ  roughly equals room temperature this weekend.

As such you would all be wrong.  These suggestions have already been presented to Congress by The Limited Partnership for Quality Home Health Care.   Click on the link to view the eight (8) members of The Partnership.  Is anyone surprised by anyone on the list?

In case you think that Bill Borne and his friends are just trying to mess with me, I encourage you to read their petition to congress.  It describes an entire proposed Act of Congress called the SHHIPS Act.

I have never had an act of congress – even proposed – named in my honor.  I want a Planet Wackadoo Act that eliminates stupid and/or greedy people from health care.    Better yet, what about a Put Patients First Act that prohibits determining care based  upon arbitrary numbers that coincidentally benefit the Elite Eight at the expense of the group of the other approximately 6,000 home health companies in the country?

As the week goes by, I will share my thoughts on the individual recommendations.  Meanwhile, we have a voice.  If you have any strong opinion about the SHHIP  – even if you disagree with me, use your constitutionally guaranteed right to be heard by those you elect to office. 

Now, go for a long walk, get some tea and clear your head.  We have work to do.

Mar 22

1 Comment

ADR Checklist

Prissy the Pit Bull available at no charge to review your records. We guarantee they will not be denied for lack of signature. We do not guarantee they will be paid.

Make no mistake that what I am about to say is shameless self promotion.  The safest way to ensure that any medical records requested by a payor source meet standards are to have them reviewed by someone with experience and who does not know the patients or the agency.  This doesn’t always ensure payment but it can alert you to your vulnerabilities so that you can make a plan before the next dance with your MAC.

Short of the the level of security offered by Haydel Consulting Services, you can do your own reviews.  More important than the actual content of the review is the attitude of the person doing the review.  Attacking the charts like a rabid Pit Bull will ensure that most errors are identified but Pit Bulls do not implement action plans.  Your reviewer needs to be cognizant of the fact that any errors or omissions identified are  tools to help cover their coworkers back and they need to be willing to help out their colleagues.  If they can be ethically corrected, they should be.  If they cannot, a team with members from every part of the organization needs to implement a plan to prevent repeat errors.

Here is what I look for:

  1. Orders signed and dated by physician.
  2. Face to face in all charts.
  3. Medications
  4. Diagnoses – note meds came first.  Are there any meds for dx’s not listed.
  5. Frequency – does it correspond to the patients’ needs?
  6. Functional status – if the patient is minimally impaired in the functional domain, are they homebound for psychiatric reasons?
  7. Is teaching original and relevant?
  8. If re-teaching is present, is the reason why re-teaching was necessary explained?
  9. Does teaching require the skills of a nurse?  It does not require the skills of a licensed nurse to tell a patient to take medications timely.
  10. ARE THERE ORDERS FOR THERAPY?
  11. Are therapy re-evals done on schedule?
  12. Is there any lab or other diagnostic tests that support care for the patient even if they were performed in a prior episode?
  13. If subcutaneous injections are given, is there a reason why the patient cannot be taught?
  14. Is there a documented predictable end to daily skilled visits when daily nursing visits exceed 21 days?
  15. If the patient is seen for Management and Evaluation, is an RN performing the visit?
  16. If Observation and Assessment is documented as a skill, are there any clear indications that the patient is likely to become unstable?
  17. Are patient and clinician signatures consistent throughout the record?
  18. Are there any hospital or MD reports that will support services?
  19. Does the clinical note contents support OASIS?
  20. Is the primary diagnosis the focus of care?

Notice again that two questions that are critical to payment are asked last.  It is only after reading the entire episode that you can truly answer these questions.

There are so many other important elements in a chart that are required in order to reflect good clinical care.  This is a payment review only.  So, if the patient had 12 nursing visits scheduled and two were missed, that will not affect payment but I want to go on record as saying that it is unacceptable to find out about two missed visits on ADR review.

If you find egregious mistakes that cannot be ethically corrected, back out the claim.  For instance, if there were no therapy orders after the initial order to evaluate and treat, back out the claim and resubmit it less the therapy.  Print all paperwork and send it with the ADR.  This will not prevent a denial but you won’t look stupid either.  After that, find the therapist culprit and violate your work place violence policy.

I am very interested in knowing who is getting denied for what.   Please email me privately if you have the goods.

And if you are not pleased with what you are finding, do not hesitate to call us.

Dec 21

Test Results

We keep receiving results from the Medicare 101 quiz.  What interests me most isn’t the scores that people in general are receiving.  Individual low scores could be the result of any number of things besides knowledge.  What I find interesting, and occasionally  amusing is the number of questions that a whole lot you answered incorrectly.

Understand that green represents correct answers and pink represents wrong answers.  Here is the result for the question that reads:

Teaching and training is a skill only if the subject matter taught would be considered skilled care by a nurse.

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And yet, isn’t that what we do every day?  We teach and train on medication administration but giving meds is not a skill.  We teach a patient how to eat a nutritious diet altered specifically for individual disease processes.  The real question to consider is whether or not the teaching is required to improve the patient’s condition.

The problem with teaching is that we never seem know when to stop.

Look at question 34.  The question read:

Your patient was admitted 7 weeks ago after being diagnosed with CHF and continues to refuse to adjust his diet resulting in multiple hospitalizations. He is able to verbalize all the components of a sodium restricted diet. As you knock on the door, you see him through the window eating a hotdog and some french fries. What do you do?

image

Most of you got it correct but a full 30 percent of you were ready to ditch the patient as soon as you could.  Could it possibly be that compliance with diets and meds might require more than education?  I used to think so but look how my peers answered the next question which read:

Which of the following is a skill?

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So let’s get this straight.  The patient knows all about a low sodium diet and yet you find him eating my two of my three favorite foods (chocolate is the third). And 43 percent of you said that teaching the patient a low sodium diet would continue to be a skill.  He knows the diet.  He is not compliant for a reason.  The reason for non-compliance is where your skill needs to be directed if possible.  It could be that the patient wishes to die and wants to prolong the process because it’s a once in a lifetime event.  Or, it could be that he cannot afford the food or is completely dependent on his son who spends most of his father’s money on crack cocaine for food so he is stuck with hotdogs and fries.  Social workers come in handy in these situations.  Revisit post about teaching versus coaching.  Try something new.  Teaching has already been tried and it apparently didn’t solve the patient’s problem.

The overall scores for the Medicare 101 quiz was 75 percent.  There are a couple of questions that I must have written poorly.  78 percent of you think that verbal orders should be cosigned by the physician prior to billing if at all possible.  There’s no ‘if at all possible’ about it.  Orders MUST be signed prior to billing.  When 78 percent of you think otherwise, I either posted this on the Federal Prison blog or the question is just too confusing.  Forgive me.  I wasn’t trying to trick you.

We are planning a two day conference which just so happens to coincide with the LSU/Alabama football game on January 8 and 9th.  The first day will devoted exclusively to the fundamentals of home health including coverage.  If you feel that you or one or more of your nurses should have scored better, consider joining us.

Dec 14

4 Comments

The Ugly Step Sister

 

Mandy

Mandy Estes, Haydel Consulting Services LLC

Okay, so it probably wasn’t nice of me to put Mandy’s photo near the Ugly Step Sister title.  It is a coincidence, I promise.  I was going to introduce Mandy to you as I published her first post for our blog but I think she did a pretty good job of that herself.  Mandy can be reached via email any time you have a question or comment.  I hope you appreciate her unique take on things as much as we do.

 

For those of you who don’t know me, I am Mandy Estes. I have gotten a chance to meet some of you lovely nurses out there when I visit, and the best part of my job is meeting new people and getting to “visit” as we like to say here in south Louisiana. I have worked in homecare for a while now for a LARGE company and a small company and now I am blessed to be employed at Haydel Consulting. Can I say I love my job? Who wouldn’t love their job, if it sometimes consisted of writing a blog about the results of a Medicare 101 quiz? Regulations and tests make me giddy.

Throughout my home health career I have familiarized myself with state minimum standards, but I had not sat down and actually read the federal guidelines from front to back until recently. If you haven’t either, you should at least get started. Below is a link to them, it contains very valuable information and will only make your agency more successful. So, let’s get back to the subject at hand.

Observation and assessment. I want to call it the ugly step-sister to teaching and training.  Overuse of observation and assessment is like sending and engraved invitation to Medicare that reads,  “Hey, Medicare send the contractor to look at my charts!”

I don’t think anyone was too sure what to do with question 46, because the guidelines are somewhat vague when it comes to continued observation and assessment after the golden 3 week time frame. I could quote the guidelines verbatim but I don’t want to bore you all so much that you unsubscribe to Julianne’s funny and informative blog on my first attempt.

In a nutshell, the guidelines say this is justified as a skill when there is a risk for complication or exacerbation, but in addition the nurse is evaluating for modifications in the treatment plan. This means they actually want us to do something about the problems we are observing and assessing, not just stand around and write a detailed nurse’s note of our findings. We have all done it; even me.

Make a plan then take action by writing a case conference or calling the doctor’s office. In order to meet criteria, the plan of care must change.

The guidelines specifically address that a longstanding pattern of watching and waiting is not reasonable and necessary.

Let’s all make a pact to read section 40.1 of the federal guidelines focused on skilled services. If you will learn something you didn’t already know and maybe you can share it with the rest of us.  Experience tells that if one person missed something, chances are a lot of people did.   Education is a powerful tool and in our industry education is a must! Stay tuned, there is more to come.

https://www.cms.gov/manuals/downloads/bp102c07.pdf

Aug 22

What’s Your Average?

I have had a lot of questions this past week about lengths of stay for home health and what they should be.  One large company in our area has begun mass discharging at several locations throughout the state causing my clients to worry that maybe the big company knows something that my smaller clients do not.  Another client has a very short length of stay and wants to know if they should extend it.

If you want to know the facts as I understand them, the Zone contractors are looking at agencies with excessively long lengths of stay.  The clients that I have had this year average around five episodes per admission.  What’s more is that the Zone contractors look at total length of time on service regardless of the number of admissions.  Many of the clinical records we review have multiple admissions and discharges.  So, if you think by reducing you average length of stay by discharging and readmitting will fool anyone, you may be right but it won’t be the Zone you fool.

There are various published numbers about the average home health length of stay per state.  The Southern states where both income and education are lower than the national average tend to have average lengths of stays of around 2.4 episodes per admission.  Some of the Northeastern states where money and education are not in short supply have a much lower length of stay.

But, I really don’t care about what your average is.  People hear that their length of stay is average or below and they breathe a sigh of relief and go on about their business.  I had an agency where most patients were on service for about a year.  However, a cardiovascular surgery group referred several patients a week to the agency who were only seen for three visits.  Their average length of stay was quite acceptable.  The reality is that most of their census consisted of patients who did not meet eligibility criteria.

To be sure, every agency has a patient that continues to come up with new ways to challenge the nursing staff.  They are admitted with DM but right before discharge they fall and break their hip.  After therapy gets them back on their feet, they have a small MI.  Later it is a stroke, etc.  As nurses, we cannot and should not look at an arbitrary number and discharge a patient because they have been on service for two years.  And even one episode is too long for a patient who is not homebound.

As most of you know, I am an information junkie.  I love the numbers and they tell me a lot about clients.  But when it comes to taking care of patients our concern shouldn’t be length of stay.  There should be no mass discharges to lower averages.  The only questions that matter are:

  1. Is the patient under the care of a licensed physician operating within his scope of practice?
  2. Are the services required by the patient reasonable and necessary as defined in Chapter 7 of the Medicare Benefits manual?
  3. Is the assessment and the care plan of the patient accurate and sufficient to guide care?
  4. Can you provide the services?
  5. Can you document the services?

Oddly enough, it is question number five that most agencies get stumped on but I digress.

If you can satisfactorily answer all five of these questions upon admission and recertification, the patient should remain on service.  Regardless of the length of stay, any patient discharged requiring home health care that is covered by the Medicare Home Health benefit is being shorted the benefits that they rightfully deserve.

Numbers give us a place to start looking.  It would be rare indeed for an agency that only keeps eligible patients on service to have a length of stay of five episodes per admission.  Upon investigation of a new client, I will certainly keep numbers in mind as I review clinical records.  However, my recommendations to the agency are made based upon the patient’s needs and conditions.

Does following these guidelines mean that the Zone folks won’t come looking for you?  Probably assuming the same guidelines were in effect for the past three years.  In addition to Zone contractors, remember we have RAC’s, state surveys, accrediting organizations and numerous other regulatory bodies who are more than welcome to visit an agency at any time and look at your records.  Be ready.  All it takes is one disgruntled employee to file a complaint or a surveyor who didn’t get enough sleep the night before to make trouble for you.  You have no control over that.  What you can control is your ability to respond successfully to any sort of scrutiny.

Questions?   Post below or email me.

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