Tag / Medicare

by Julianne Haydel

Targeted for ADRs


Every so often, Palmetto posts a list of the claims that will be of interest to them on their website. This is the list that was published on August 4.

Note the last letter of the HIPPS code. The letter ‘L’ indicates 16 – 17 therapy visits and the dreaded ‘K’ means that 20 or more therapy visits are scheduled. Only one of the edits is for therapy below 14 visits. In that edit, Palmetto GBA is looking for the lowest clinical and functional scores together with therapy.

Palmetto is asking why a patient who appears to be clinically stable and can walk, talk, bathe, transfer and dress themselves needs any therapy. It’s a good question. There could be a perfectly legitimate explanation but if it is not documented well, you are looking at a denial.

Pretty much all episodes with 20 or more therapy visits are being scrutinized. These are the expensive claims and people who are ‘gaming’ the system will often use high utilization as a method to do so. This does NOT mean that a patient should not receive 20 therapy visits if needed. For most agencies, these episodes will be few and far between.

16 and 17 visits are very profitable as well even if the dollar amount is not the same. The profit starts to drop off at 18 and 19 visits until 20 visits are made.

All clinical documentation should support the services billed but in an agency where staff is limited or compromised at time of billing, claims with these HIPPS codes might be prioritized for review prior to dropping claims.

1BGP* 0 – 13 Visits, Lowest Scores in the Clinical and Functional Domains and Maximum Score in the Service Domain
2BGL* 16-17 Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
2CGL* 16-17 Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
2CHL* 16-17 Therapy Visits, High Score on Clinical Domain, High Score on Functional Domain
5AFK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Low Score on the Functional Domain
5AGK* 20 or More Therapy Visits, Low Score on the Clinical Domain and Moderate Score on the Functional Domain
5AHK* 20 or More Therapy Visits, Low Score on the Clinical Domain and High Score on the Functional Domain
5BFK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Low Score on the Functional Domain
5BGK* 20 or More Therapy Visits, Moderate Score on the Clinical Domain and Moderate Score on the Functional Domain
5CGK* 20 or More Therapy Visits, High Score on the Clinical Domain and Moderate Score on the Functional Domain
5CHK* 20 or More Therapy Visits, High Score on the Clinical Domain and High Score on the Functional Domain
All Aggregate Length of Stay and Disbursement/Beneficiary
All Home Health Services

 

by Julianne Haydel

More than Half!


More than half of the dollar amount of claims reviewed by one intermediary were denied in the last quarter of 2014. Multiple results were published this past week. Most were for smaller amounts but the denial rates were similar. The results posted below are the results for an edit of claims with a HIPPS code of 1BGP*. These are patients who were in an early episode, a clinical severity of 2 and a functional level of two, and a service level of 5. This represents a very high paying patient who is receiving therapy but otherwise isn’t all that sick.

Over half of the dollars that were billed for these claims were taken back or not paid because of a focused medical review.

For now, this is where we stand. As unfair as it may seem, there is no other option than to address these numbers until your claims make their way through the appeals process. Please do not think you are being told to grin and bear it because we are angry, too.

Region Midwest Southeast
Total dollars reviewed 6,074,393.71 5,588,813.76
Total Dollars denied 3,498,994.66 3,285,618.64
Denial Rate 57.6 58.8

The good news is that most of the claims were denied for Face-to-Face encounter documentation and we can obviously expect fewer denials in the future but not for several months. The claims that will be scrutinized for the next several months will all have required Face-to-Face documentation.

The bad news is that many of these claims were denied for multiple reasons. For instance, in the Southeast Region, there were a total of 1817 claims reviewed producing 1562 denials. There were 865 claims that were denied because ‘MR HIPPS Code Change  – Documentation Contradicts OASIS MO Item(s)’ Look for this denial related to diagnosis coding and therapy. The functional and clinical domain (except for diagnosis) can change but the diagnosis coding should be fairly static throughout an episode unless there has been change.

What can you do?

Agencies need to fight fire with fire. If it’s details they want, give them every detail you have. Deprive them of the opportunity to take your money back.

  1. Admit all patients with a goal of one episode at most. Any further episode must be approved by someone who has reviewed the chart.
  2. Involve the entire staff in educating each other about documentation.
  3. Constantly remind nurses who already document well that the increased focus is not about them but getting paid.
  4. Documentation takes time and should be included as part of the visit rate. If nurses are running the roads all day and producing sloppy documentation at night when they are tired, visits need to be backed down until all work can get done.

The best solutions will come from within your agency. Take advantage of each individuals talents and get everyone involved. Post excellent notes where everyone can see them.

If you think you cannot afford this level of attention to detail, you might rethink that position if you are hit with an edit.

We can help prevent that with our fabulous coders who will ensure proper coding so the careplan can be written within a couple of days and followed to a T.   Call us or connect by email.

 

 

by Julianne Haydel

Incarcerated Prisoners


 

 

The telephone is often our most sacred source of amusement.   We love email, texts and blog comments but there are some things that people will not commit to writing.  When we need a break, we simply turn our volume up and answer the phone.

The question of my day was, ‘If a patient moves, can we still see them if they are in the service area?”

The answer was too obvious so the caller was answered with a question.  “Where did the patient go?”

The answer was less than articulate but the word ‘jail’ was in there somewhere.  Apparently, the patient got a little tipsy and loud and someone called the police and there were outstanding warrants and he is taking a little vacation courtesy of the county.

Not wanting to give bad advice, a little research was done on behalf of the caller – after all, this was cheap entertainment.  What we found, though, was not as amusing as we had hoped.  The definition of incarcerated includes beneficiaries who are:

‘• Imprisoned;
• Escaped from confinement;
• Under supervised release;
• On medical furlough;
• Required to reside in mental health facilities;
• Required to reside in halfway houses;
• Required to live under home detention; or
• Confined completely or partially in any way under a penal statute or rule.

The patient is not eligible for services.  This is important.  If someone is incarcerated, the incarcerator picks up the tab for all medical expenses.  (Consider that if you don’t have insurance and need surgery.)

If you are providing services to someone who has escaped from confinement, you have bigger problems and my recommendation is to pretend you do not know that your patient is an escaped convict.  If you let on that you know, you may experience a sudden reduction in staff.   If your conscience bothers you, don’t bill for the care and enter into a Corporate Integrity Agreement with the OIG when you are able to safely discharge the patient.

The risks to home health and hospice providers are further down on the list.  The United states has more prisoners per capita than any other country and Louisiana tops the list of states with 867 people per 100,000 meeting the definition of ‘incarcerated’ as provided above.  And yet, earlier in the week, researchers from Harvard University together with the University of British Columbia announced that they have determined that the five happiest cities in the nation were in Louisiana.   (Mardi Gras?)

In fact, it appears as though CMS Region 6 is well represented in the list.  In addition to being Region 6 states, it is noted that all of them are in the South and none of the very cold states have many prisoners.

Medicare Regional Map and Density of US Prison Population

image

But, you have a bigger problem than the weather in Region 6.  Specifically, it appears as though the various prison systems across the states are very slow to update their systems.  In some states, Medicaid is auto-cancelled when someone is incarcerated.  Released prisoners do not always know to reapply.  In other states unless someone applies to be taken off of probation they will remain on probation until a judge approves their release.

Medicare is denying claims for the incarcerated.  States can decide if they want to use Medicaid dollars but most don’t.  The ones that pay for prison healthcare forego the matching Medicare funds.  In Louisiana, we don’t have to worry about those required to reside in Mental Health facilities because our jail is our mental health facility but like everyone else we need to be concerned about halfway houses, supervised release and those on Medical Furlough.  If a patient on House Arrest gets past you, shame on you for not checking pedal pulses.  You don’t deserve to get paid if you missed the ankle bracelet.

If you inadvertently bill for a a person who is under the jurisdiction of the court, it will result in a denial.  If you live in one of the northern states, this should be an isolated incident.  If you live down south, it could become an expensive issue.  Medicare is supposedly getting on to states to tidy up their prison rosters but meanwhile, if you live in a state like Louisiana or Mississippi, my suggestion is, quite frankly, to include an assessment of their legal history at time of admission.  Don’t be rude about it.  Just ask something like, ‘Are you able to transfer from both the top and bottom bunk?’