Don’t Archive Your Agency


When the list of documentation required by AdvanceMed  for UPIC audits included a complete Medicare census, we were confused; or rather, we thought they were confused. Surely they can get their own lists based on any number of databases.
A report by the Office of the Inspector General reveals they are not confused. The OIG has noted that 9 of 28 agencies reviewed had discrepancies between Medicare data derived from claims and Casper and the list provided to surveyors at the time of state survey. It is this list that surveyors use to choose patient’s and they were not inclusive of all patients Medicare has on their lists.
Occasionally a difference of one or two patients can be explained. Many times a ‘missing’ patient is a typo -sloppy but not fraud. Changing out computer systems can be messy. Yet, when an agency presents a list to surveyors that is 150 patients light, equal to 90 percent of their patients, a very bad outcome is lurking on the horizon. Active patient lists that are incomplete ensure that absent patients are not visited by surveyors. In some cases, patients were omitted from the unduplicated census resulting in surveyors being unaware that the patient existed.
The OIG has arrived at the conclusion that while there are many possible reasons for these omissions, some agencies might be deliberately trying to avoid scrutiny for the omitted patients. Honestly, do you feel just a sorry for the OIG because they are only just now arriving at this conclusion?
The OIG also noted that patients were discharged from one agency on the day that the roster was requested by surveyors eliminating them from the ‘active patient’ list. These same patients were readmitted later in the year with no intervening events or claims from other providers such as hospitals, rehab facilities or other home health agencies. There are references a prior report that found frequent discharges and readmissions were often characteristic of fraudulent agencies.
The OIG suggests a couple of possible solutions to ensure that the list given surveyors has not been manipulated by the agency.
  • Instead of using an agency provided list, arm surveyors with a claims list provided by CMS
  • Spot check by asking an aide or a nurse about their patients and determine if all of those patients are on the agency provided lists.
  • Monitor the person in the agency who is running the list from the computer. Doesn’t this sound like fun for both the surveyor and the agency?
  • Conduct a retrospective review post survey using Medicare claims or Casper data.
Obviously you are not going to manipulate patient lists but it will instill confidence in surveyors if you are able to provide accurate information in a short period of time. Because surveys are unscheduled, multiple people should be trained to:
  • Run an active patient list
  • Run an unduplicated census (list of all patients regardless of the number of times they have been admitted. Each patient will be listed only once).
  • Run a duplicated census (the name of every admission regardless of whether the patient has been admitted more than once. This list is longer than the unduplicated census list.)
  • Speak intelligently about any potential flaws in your data and offer a work around. (Your biller should be able to provide a list of RAPs dropped or a referral log from the computer)
I know that agencies have rushed to ‘archive’ records of patients that who don’t have anything good to say about the agency and records that might be train wrecks due to documentation errors or poor care. Surveyors are very much aware that these patients exist. All agencies have at least one or two.
Unless care is egregious, state surveyors will allow the agency to provide a corrective action plan. If the deficiency is a repeat or widespread throughout the agency, you may be subject to financial sanctions and a hold on admissions until corrections are implemented and verified by the state agency.  It’s embarrassing to be certain but rarely fatal.
If you provide false information to the surveyors, you have crossed a line into a whole new level of non-compliance. Your Provider Agreement has been violated and you are at risk for losing your agency’s license or worse. And yes, there are consequences worse than being shut down because you have no license to operate.
Most agencies want to do the right thing. Knowing that the agency down the street with patients who do not need care or are not homebound and yet has a perfect survey while your agency has five or six deficiencies has been known to boil the blood of nurses but at least they know where to focus attention.
The agency that hides patients from surveyors now has a very real chance of being caught.  Depending on how patient lists are compared, it may take a while, too, contributing to insomnia.  If you have archived patients to avoid scrutiny, consider keeping a current passport handy. This could be fun.

 

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Computer Charting


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Computers are tools.  They give your staff the ability to surf the net, check FaceBook or even work.  Sometimes, surfing the net would be preferable to the computer documentation I have had to suffer through lately.

This is not a new pet peeve but it is regularly exacerbated.  One idea is to turn off the software’s ability to carry over visit note content from one day to the next.  Agencies are afraid their nurses would quit if they did that.

Just two weeks ago, I wrote a plan of correction for an agency that addressed essentially duplicate notes.  It seems the surveyors are also noticing very little original content in visit notes.  The plan my client decided on was to disable the ability to cut and paste for one week for an initial offense for a nurse, a month for the second and permanently for the third.  This only works if you system allows you to individualize each user’s abilities.

Everyone uses templates and revises old documents and contracts to make new ones.  Everyone’s phone rings and has distractions.  The difference with clinical documentation is that typo’s are the stuff of Medicare Fraud and Abuse.

Do you know Daniel R. Levinson?   He holds the position of Inspector General of the United States.  When someone refers to the OIG, they are referring to his office.  Unless you are paid handsomely to defend someone against charges brought by the OIG or you play tennis with him, you never want to hear your name in the same sentence as Daniel Levinson’s.  So, having said all that about the Inspector General, let’s hear what he has to say about your computer documentation.

Experts in health information technology caution that EHR technology can make it easier to commit fraud. Certain EHR documentation features, if poorly designed or used inappropriately, can result in poor data quality or fraud.

This next one kind of gets under my skin a little but he is absolutely correct.  I just wish he would remember that the most important reason to document is to improve patient care by committing to writing pertinent facts about the patient and their treatment.

When doctors, nurses, or other clinicians copy-paste information but fail
to update it or ensure accuracy, inaccurate information may enter the
patient’s medical record and inappropriate charges may be billed to
patients and third-party health care payers.

The Inspector General highly recommends the use of audit tools, as well.  I’m not sure that is an effective solution to all but the most egregious offenses.  The nurses I know sign their name to duplicative documentation.  I know nurses who share passwords all the time.

The only time that I have ever detected the appearance of actual fraud is when nurses documented more visits than are possible on a single day with over lapping times.    I know from frequent experience that it is easy misdate a handwritten signature or document.  Computers are far more reliable than most humans in getting the date straight.

The best audit tool begins at the hiring process.  People with integrity do not commit fraud.  We have all been desperate for someone to fill an urgent need in the schedule and plugged in the wrong person who had not been vetted properly.   That’s a painful mistake because ultimately, the agency is responsible for what happens inside its organization.

The second best audit tools are the back office people and coders who read scores of documentation.  They will notice duplication and unlikely events sooner than a QA nurse who is reviewing a smaller percentage of clinical records.  Coders and billers spend hours of time at computers each day.  They make scores of errors, correct them and move on to the next plan of care.  When they see an obvious typo, they don’t see it as Medicare fraud because, get this –nobody is actually trying to commit fraud.

The only people who view these typos and occasional duplicated notes as fraud are the ones who can deny you payment or arrest you.  If I were you, I might take a second look at your computer documentation practices.

Just saying….