Posts tagged ‘UPIC’

May 1

Denied?

If you saw the list of UPIC denials a client recently received you’d probably want their license pulled. I would have stopped working for them to be honest if I hadn’t already read the charts.

The first red flag was that there were multiple denials for each chart. The second red flag was that many denials repeated themselves in essentially every claim on the list. There were approximately 60 clinical records and after my initial horror subsided, I started pulling charts one by one.

I know we all forget to add pertinent things to the plan of care from time to time. But did my client neglect to include wound care orders on almost 60 patients? Truthfully they did not include wound care orders on about 45 – 50 patients. But that’s understandable when you consider that these patients did not have wounds. The patients with wounds had orders.

The reviewers recognized the physical limitations of patients who were confined to the home but determined that the patients were not homebound because there was no documentation that it was medically contraindicated for the patient to leave home. Let’s review. The patient has to meet certain criteria to be considered confined to the home. They can be found in section 30.1 of the Medicare Benefit Policy Manual. The patient must meet two criteria. There are two ways to meet Criteria One. The word ‘OR’ in all caps indicates that this is an either/or situation.

The patient must because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence

Have a condition such that leaving his or her home is medically contraindicated.

If they meet Criteria 1, they must also meet criteria 2 which has two components and both of these must be met.

There must exist a normal inability to leave home;

AND

Leaving home must require a considerable and taxing effort.

The patient who relies on a walker with human assistance and is short winded after 10 feet does not need to have documentation that it is medically contraindicated that they leave the home (assuming that they do not leave the home often).

I’d like to assume that you know this but if the contractors who are ensuring your compliance to Medicare coverage regulations don’t know it, I can’t very well expect you to know it.

More than one chart noted that a patient had a caregiver in the Medical Necessity section of the reasons for denial. Please note that the presence of a caregiver does not disqualify a patient from receiving home health services. That would found in section 20.2 of the Medicare Benefit policy manual. If the caregiver is willing and able to meet all the patient needs, then home health would not be necessary. It is rare that a caregiver knows all of the medications, can give injections, perform wound care (if the patient has a wound) and know what out of range parameters need to be reported and to whom they should be reported.

All of the denials included the fact that there was no measurable level of understanding by the patient of teaching. Let’s assume that the caregiver is included. On every single note by the agencies in question, the nurse documented that the patient understood or partially understood the teaching provided. But just for fun, let’s go back to our Medicare Benefit Policy Manual. It lists those services that are usually considered covered and the circumstances under which they are covered. It can be found in section 40.1.2.3 See if you can find anything about documentation of a measurable level of understanding of the patient’s understanding.

Teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family, or caregivers how to manage the treatment regimen would constitute skilled nursing services. Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered. The test of whether a nursing service is skilled relates to the skill required to teach and not to the nature of what is being taught. Therefore, where skilled nursing services are necessary to teach an unskilled service, the teaching may be covered. Skilled nursing visits for teaching and training activities are reasonable and necessary where the teaching or training is appropriate to the patient’s functional loss, illness, or injury.

Where it becomes apparent after a reasonable period of time that the patient, family, or caregiver will not or is not able to be trained, then further teaching and training would cease to be reasonable and necessary. The reason why the training was unsuccessful should be documented in the record. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient’s illness, functional loss, or injury.

In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction. Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered. Where the teaching constitutes reinforcement, an analysis of the patient’s retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits. Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home. Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.

Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient’s condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.

I know this is a lot but should your agency ever have records requested, you must be familiar with these (and all) the coverage guidelines. It is reasonable to believe that the contractors are authorities on the coverage guidelines. Although they have made mistakes before and been overly tedious in my opinion, I have never seen such creative writing in denials. Worse, all of the stated reasons for denial should be addressed because the assumption might be that you agree with the reason for denial if you don’t. That’s a lot of time, folks and your deadline is 30 days.

You work hard for your money. More importantly, you work hard for your patients. That’s where your focus needs to be. If anyone else has dealt with a UPIC audit like this, please email or call me at 225-253-4876.

May 22

5 Comments

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.

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.
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.
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.
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.
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.
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