Does this seem wrong?????

CapeCodMermaid, RN · Jun 21, 2007

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.

cookie102 · Jun 22, 2007

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

Narcoleptic Nurse · Jun 22, 2007

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.

homehealth43130 · Jun 22, 2007

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.

caliotter3 · Jun 25, 2007

I can certainly attest to the fact that most of the time it does not pay to get known as a rabble rouser. It does not take long to figure out that you aren't supposed to bring anything to the attention of those that are responsible for seeing that cheating does not occur. Based on what you have posted, if I were you I would definitely make plans to move on. Your only alternative is to completely shut up and acquiesce. If you do that, then you will still have to worry about going down with the ship should they be taken to task by the authorities (it does happen sometimes), or you will be waiting for them to get rid of you or make you miserable in the hopes of getting rid of you. You've already been marked as a trouble maker. Trouble makers are dealt with sooner or later. Good luck in finding a place where this sort of behavior is not happening. I hope that you aren't in dire straits about needing steady employment. It might be harder getting your next position.

runrn · Jul 5, 2007

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.

renerian, BSN, RN · Jul 6, 2007

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

renerian

Narcoleptic Nurse · Jul 10, 2007

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.

Home Health Columnist / Guide · Jul 11, 2007

Having 9+ episodes is unusual unless the patients are having exacerbation's of acute illness, medication changes , multiple unskilled caregivers and actively being case managed along with being truly homebound.

Cases with therapy must show progressive gains; if status unchanged after 3 visits then pt considered plateaued and therapy needs to be stopped. If SN still in and functional status significantly declines after therapy stopped, doctor can order PT to go back in for an eval and further treatment as long as positive progress being done and just not maintenance TX.

Most of our therapy cases are completed in 1-2 episodes; 3, maybe 4 episodes is for patients with CVA, neurodegenerative disorder, traumatic brain injury, extensive burns, possibly exacerbation MS.

Brittle diabetics, CHF/COPD patients and catheter maintenance patients may have PT periodically come in for few weeks during exacerbation's of illness where ther's rehab potential while being case managed and in 9-12th+ episode----even then it's probably about 5% of our total patient population......in agency with 1,500+ admits/month.

In a small agency with census of 75-150 patients, or those working with office of aging nursing home diversion clients----not unusual to see close to 75-80% patients with multiple episodes. Just gotta be able to document strong homebound status, case mgmt activities, med changes, exacerbation's , rehab potential, physician contacts and active care plan changes when chart pulled (called 488 review) by medicare intermediary.

caliotter3 · Jul 11, 2007

NRSKaren

Thanks for the clear and thorough explanation. Supervisors at work usually don't have the time to explain things like this to those of us that want to know the whys and wherefores and are not working at the level where many concepts are common knowledge already.

Home Health Columnist / Guide · Jul 11, 2007

Took me 15+years to understand this stuff. Really helped when I started to manage Philadelphia Office of Aging Option and Wavier clients who's focus is nursing home diversion---keep em home and healthy.

Primary insurance is always first payer for SKILLED needs. When there are no more changes going on with the care plan (except for foley cath, enteral & trach pts needing tube change) patient then falls into "maintenance", therefore non-skilled care. Skilled care then ceases under Medicare....and services will start/resume if in Options or Wavier Nursing home diversion programs (Monthly SNV to assess physical systems, eval med compliance, home safety and eval care plan) under secondary Medical Assistance payer.

For patients not receiving Office of Aging care, have traditional insurance or Medicare Manged care with frequent ER visits/multiple hospital admits, insurance companies will often allow multiple episodes for patient to be case managed to be kept out of the hospital.

One ER visit is usually several thousand dollars $2,000-$3,000. Average SN visit payment $75.00-$100.00/visit.

2x/wk x 4 weeks = $800.00

$2,000-$800 = $1,200 savings

$3,000-$800= $2,200 savings

Explain that to the insurance company and savy Case Manager will readily agree to homecare.

Running joke:

If your over 62, are coughing, sneezing and homebound, Karen will be able to finagle homecare for ya!

Once you learn the rules, can clearly document functional deficits and associated patient problems, issues with care giving, becomes easier to get homecare ordered and paid for by insurance companies.