Does this seem wrong?????

I recently started a new job as a case manager. As I am finally getting to look back into records I am seeing that this agency has a strong pattern of never discharging anyone they can get a new 485 signed on. So many patients have many (9+) cert periods, I haven't seen that in years. Amazingly they get 10-12 visits from therapy every cert period. never more or less. They all seem to have either muscle weakness or diabetes as primary diagnosis. I really became alarmed when a patient's son told me his late stage alzheimer's mother gets PT just so the agency can make an extra 2 grand. It made no difference in her functional ability. Where I come from and in my many years in home health I have never seen this as being an OK thing. I know what I have to do for my own integrity, I just want to know if this is seen anywhere else. I could give more instances but I don't want to get identified. I got chastised as a rabble rouser my first week when I asked if something I saw would be upcoding and therefore fraud. Anyway I would appreciate some feedback

Would that demented woman have gotten WORSE without intervention?

Certainly if this is a pattern with this particular agency, Medicare would have done something if there were fraud involved. I am relatively new to home health and am amazed at how long some people stay on service.

on some occasions you can see that patients need to be recerted, for example: you get ready to d/c and they end up in the hospital, come out,you recert etc....but they should not be getting PT every cert period, if they need only 10=12 visits to meet the high end theraphy and PT d/c's them and then sees them again the next cert period, there is def something wrong with that!!! medicare has so many audits to do, it this agency isn't due or no one alerts them they are not going to be aware of it......sounds wrong to me

Thanks for responding. I know I will not stay here. This is but the tip of the iceberg of questions I have about this place and I was already told not to rock the boat. They show up OK on the state report but the last reported survey was shortly after it was opened. I have been in Home Health 16 years in several states in the Northwest and I have never seen anything like the creative interpretation I am finding here in the South. I am too old and not that stupid about regs to sit here with my mouth shut and accept that what I am told is fine because they have never been told different. Especially when I am told not to question. As to the first question about the patient, The son said it had not prevented her decline and he could see no improvement. If it were the one case I might not be alarmed, but there is a definite pattern here.

My only personal concern is how many more places are like that. I am suddenly getting a job hopping pattern on my resume. My first boss here was also into creative financing, taking my part of the insurance payment out of my check and not making payments, cost me a bundle when they denied a big claim. For the first time in years I am thinking about looking in a new direction.

Some of the reforms to PPS are coming down for just the reasons you mentioned. OIG audit on therapy for 2007 and 2008 is looking at number and reasonable and necessary requirement for therapy as well as length of visits. Question would be is all that therapy reasonable and necessary and when does it cross over to maintenance therapy which isn't covered. I'd be leaving also if thoes practices were going on. Don't look all that good in stripes or florescent orange.

First of all, you are not going to change anything there. And by the sound of things, there is a lot to change. What you can change is your involvement with it by changing employers. Believe it or not, there are agencies in this business that do things the correct way yet are still able to be profitable and keep folks employed. The truth is, they may never get caught. The flip side of that is: in this day and age it has become common place for employees to file qui tam or "whistleblower" law suits. I'm sure most are familiar with these terms. It basically means when someone (usually an employee of the offending agency) has actual knowledge (that can be proven) that an agency or employees of an agency are committing fraudulent acts within the medicare (or government payor) system, they file a lawsuit against the agency. If able to prove the agency was indeed fraudulent then the employee who brought this behavior to the light is able to receive payment up to 1/3 of the amount of fraudulent payments given to the defendants. So if an agency made 300,000 dollars from their fraudulent billing, then the employee would receive up to 100,000 dollars. Not too shabby for a rable rouser.

May I ask the pay source for the clients? With Medicaid a person might have that happen more than Medicare.

renerian

Thanks for your answers, I left with no regrets and have been welcomed back to my old job for now. I have been approached to sell home health software and am getting some more time in on my web business. I appreciate the support and answers I find on this site.