Posts tagged ‘Palmetto GBA’

Apr 30

Palmetto’s Naughty List

If you are one of the 398 providers who had over 100 RAPs cancelled in the first quarter of this year, that might be a problem soon.

Palmetto GBA makes it abundantly clear that payment is not be withheld – rather an agency’s privileges to Request Anticipated Payment will be suspended and all payment will be held until the final claim is billed. Agencies will also have to complete a corrective action plan and demonstrate compliance prior to having their privileges restored.

Other agencies may get a letter warning them to clean up their billing act or face a 0 percent rap payment in the future if they have between 50 and 100 RAPs auto cancelled.

For those clinicians who stay far, far away from billing, you probably already know that 50-60 percent of payment is made for a home health episode at the beginning of the episode and the balance paid when the final claim is dropped. At least, that is how it works. What technically happens behind the scenes is that when the final claim is dropped, the RAP is taken back from the agency and the total amount for the claim is paid. An agency has about 4 months to bill the final claim prior to having the RAP cancelled. (Thanks to all you business office people for reading patiently while I got the nurses and therapists up to speed).

I am in complete agreement with the underlying reasoning for the suspension of RAP payments in agencies with a high number of auto cancelled RAPs. It is a patter that I see frequently in agencies who will not survive a ZPIC or RAC audit. I do not agree with the way they implemented it.

Before asking agencies to correct the problems, Palmetto should have first asked why the problem occurred. RAPs auto cancelled in the first quarter would include those patients who were admitted as Medicare patients and later converted to an HMO during open enrollment in November of 2012. Floods and fires can destroy a building resulting in the need to obtain signatures a second time. Physicians leave the country for weddings and decide to stay 8 or 10 weeks longer than planned.

So, I don’t think Palmetto GBA should have implemented this drastic policy prior to asking agencies if there was a reason.

I am also confused by the use of an arbitrary number. It seems to me – someone who works with fraud on a regular basis – that the likelihood that program integrity is threatened is reflected by the percent of auto cancellations as opposed to a raw number. I am not the world’s best mathematician but I have seen fraudulent agencies who had about half of their RAPs taken back. They did not withstand scrutiny, by the way. On the other hand, the agency with 800 patients with an average length of stay of less than one episode may drop close to 500 RAPs per month so 100 auto cancels would equal close to 8 percent in a quarter. That seems more like inefficiency to me.

So, if you find yourself with a sudden need to write a corrective action plan, please let us know. Not only can we do that for you but I know a hotshot biller who will make sure you never have this problem again.

Nobody can do anything for you if the doc who gave the order lives in a Federal Penitentiary, was a resident at a local hospital ten episodes ago and has since returned to their homeland, or you accidentally admitted a patient to a physician who didn’t have license. Save your money and call someone else if your plan of correction will involve any of those issues.

Dec 18

11 Comments

Denial Shock

It’s a patently bad idea to share my frustration regarding people who can make or break my career on the internet but after this weekend of working denials, I’ll take my chances.

The first denial I dealt with was the result of a ZPIC audit. Somebody from AdvanceMed called a patient on the telephone and asked him if he drove. He assured her that he did. The telephone interviewer, having heard what she wanted without assessing the patient, denied close to 30k in claims.

I actually visited the patient. I also read his plan of care and medication list and couldn’t help but notice that he was on three or four pain meds that would make it very difficult, indeed, for him to get a driver’s license, but you never know. The drive to his house included a 15 minute stretch on a country highway, another two miles down a gravel road and then the dirt road. The trailer itself sat on over an acre. He had to climb five stairs to get inside and his scooter which was referenced in the denial was under the carport rusting. It seems that it is fairly cumbersome to operate a scooter in a mobile home where three adults and three children live.

But, what sold me on the homebound status, other than his five back surgeries, his lack of a vehicle or a license, his extensive medication list and the challenging physical environment in which he lived was the diagnosis of schizophrenia. As early as that morning he reported having a conversation with his sister who died tragically two years ago. He said he usually took Zyprexa and Seroquel but he didn’t that day because he had gone to the doctor to talk about back surgery.

The next denial was for $3,500.00. It involved a claim with 7 skilled nurse visits, 9 therapy visits and a few home health aide visits. The reviewer at Advance Med noted that there was no order for the visit to discharge the patient from therapy services. I went back through the original scanned copy sent to the Zone and found the order. So what? Everyone makes mistakes and it was difficult to find.

The claim was not downcoded, you understand, but completely denied. In full.

My client appealed to Palmetto who upheld the original denial. My job this weekend was to explain how the Home Health Prospective payment system worked to entities contracted with our government to monitor the integrity of Medicare payments. That annoyed me. I get paid by the hour so maybe I over reacted but I assure you that there are far more useful things I could be doing for clients.

Lack of therapy orders for another client was the target of yet anther inane denial for a different client. The client appealed AdvanceMed’s decision to Palmetto who reviewed the two signed orders (the 485 and the physician signed therapy eval and care plan) and agreed that AdvanceMed overlooked both orders. However, the decision was noted to be ‘unfavorable’ (I love that word) because there was no distinction between short term and long term goals on the plan of care.

They were right. What can I say? Who really wants to hear that the entire course of therapy lasted only three weeks?

The most uncomfortable denial I worked this weekend was a claim that was part of a ZPIC request that my company prepared for a client. They were paper charts pulled from old storage and our job was to put them order, verify signatures and notes, identify any outstanding vulnerabilities, scan 35,000 pages of documents and get them to the Zone on time. I know you won’t believe this but we, uh, sort of…, well….. we made a mistake.

The claim I was reviewing had orders in it from 2010; a full year after the 2009 denied claim. I missed it. AdvanceMed missed it. Palmetto missed it. And now its back to me. I found myself in the awkward position of pointing out that we sent in documentation that implied orders were written in March of one year that were actually written 12 months later. Not only did Haydel Consulting totally miss the ball on this one but so did AdvanceMed and Palmetto, GBA. I would like to take this moment to point out that unlike AdvanceMed, I do not have a 105M contract with my client.

What can you learn from this?

At least once episode, fully explain the patient’s homebound status. Being confined to the home due to pain and the need for help to leave the house will do on visit notes but once an episode, put it all together in context in case clinical record is requested for a payment review.
If any claim is requested contains therapy, go buy a red Sharpie and draw a circle around the orders. Make sure each page of the chart is numbered at the bottom. Reference the therapy orders by page number in your cover letter.
Include that the patient will win the Nobel Peace Prize prior to his or her death on all therapy care plans. That way you can google the winners each year and monitor progress towards goals.
The regulations state that all orders must be dated. Apparently, it doesn’t matter what date you put on the orders as long as they are dated.
Haydel Consulting Services is not perfect or known for exploiting our warm and friendly relationships with Medicare contractors because we don’t have any. Hire us anyway because we get results. Somehow.

Should I send an invoice to AdvanceMed and Palmetto or let my clients pass on my bill to them? Maybe CMS could pick up the tab for educating their contractors.

I can’t wait to see what comes up next. You’ll be the first to know if I am not in jail fighting accusations of healthcare fraud because I sent in orders that were a year late.

Please keep me posted of any creative new denials you receive.