Medicare Probe

req_read · Jan 5, 2008

AnabelRN…

You have my sympathies, and I am sure the sympathies of many others who visit here. If you find yourself looking for a new job, presumably with another hospice, I am sure you will now know better what to look for.

OneThunder…

Your attitude is condescending and sarcastic (and yes, angry too) while your perspective is hopelessly biased. The technique of inserting red text into my posts seems calculated to give the impression of providing comprehensive responses. Despite appearances however, many of your responses are defensive, evasive and fragmentary (not to mention, condescending, sarcastic and angry.)

Regarding the issue of why nursing homes are so heavily regulated…

That did not come to pass by accident. The director of Medicare did not wake up one morning and think, “I know… let’s go out and try to make life difficult for the nursing home industry.” Neither was it a simple matter of Medicare not wanting to pay, nor a result of a “game” (documentation > regulation > documentation > regulation etc.) Those things have some relevance, but as secondary effects, not as primary causes.

When I was a kid my momma told me to choose my friends carefully. She said if you hang out with trouble-makers you will be seen as a trouble-maker yourself. I did not always heed her advice, but it was good advice just the same.

The nursing home industry has a long history and reputation for bending the rules. When that happens, Medicare tightens the rules. It is not that they don’t want to pay, it’s more a case of - they don’t want to get fleeced. And naturally, tightening the rules means requiring more documentation. Historically, as Medicare (and insurance companies) tightened the rules, the nursing home industry found new ways to bend them… so the rules got tightened more and round and round it went… bending > tightening > bending > tightening, etc. Following this process, the tightening eventually reaches the point of infarction.

As I say, hospice is relatively new. It’s designers and founders tried to avoid problems that had gone before, and one of the keys to their initial success was, they avoided bending the rules. For a long time they kept their noses clean and suffered very little interference from Medicare. If anything, their good record resulted in a relaxation of the rules (dropping the old certification period system for example.) The original hospice people knew (like all pilot programs) they were being watched. To keep their program alive they had to be scrupulous.

But eventually hospice was accepted and settled in… and then the business people in hospice started eyeing the nursing home industry. The nursing home industry was being squeezed (largely of their own making) and needed help. Hospice business people saw a golden opportunity and began pressing for the chance to avail themselves of it. Eventually they got the go-ahead to start providing care in nursing homes (as opposed to assisted living homes.) And now we are seeing the result (as in the case of AnabelRN above.)

Pardon another childhood analogy, but I grew up on a dairy farm. We never had much money so made do with what we had as best we could. Back then I learned to “fix” machinery with haywire. Later (as a nurse) I saw that nurses do much the same sort of thing, but with tape instead of haywire.

Back then most tires had inner-tubes. In the course of farming, flat tires are all too common. To save money we usually put patches on inner-tubes rather than buying new ones. Eventually however, some of those inner-tubes started looking a lot like quilts! The rubber grew old and less pliable and even some of the patches sprung leaks. At some point it became necessary to do a cost analysis. “Let’s see now, what am I spending on patches and time spent patching? Would I be money ahead to just go and get a new inner-tube?”

In that sense, the nursing home industry is rather like an old inner-tube, covered with patches. You might also say it is like a drowning person. When the lifeguard (hospice) swims out there to help, the first thing to remember is that they could take you down with them.

AnabelRN…

I realize this may come a little late to help you in your current situation, but keep it in mind when looking for a new hospice.

Few would argue that the healthcare reimbursement system (or lack of one) needs a major overhaul. Even healthcare itself, when motivated purely by profit, tends to get a little twisted. Note for example the plethora of advertisements by pharmaceutical companies on television, many of which are prime examples of: First, convince them they have the disease, then sell them the cure. In our current system, convincing people they are sick is a lucrative business.

And finally, I recommend watching the movie, “Sicko.” Yes, it is slanted towards the director’s perspective… but certainly no more than (if as much as) OneThunder’s.

Michael

PeacePisceRN · Jan 7, 2008

oh, my gosh this is happening to my hospice too! the medicare probe, i mean. i haven't had time yet to read all of the responses to this thread but what an eye opener this is! i work for a non-profit agency. our census has dropped from over 200 in the beginning of last year to just under 80 right now. our executive director as well as the woman below her have left. seems like almost everyone else in the agency has cut their hours to part time. my manager told me this week that "rumor has it" that my position (weekday on call) will be eliminated by next week. :angryfire she's an idiot. anyway, i'm so glad i found this site! our unfortunate situation has always been advertised to us by the powers that be as sort of a "poor us, what did we do to deserve to be all but cut off from medicare" and now i realize (duh) that it was the agency's mismanagement and not following clearly outlined medicare rules that got us in trouble. those money hungry a-hole b%$#&*ds are about to cost me my job!

our probe is finally over. :w00t: thankfully, my job survived...so far. but, we have lost many nurses and many others are so unhappy. the office is a most unpleasant place to be. everyone's nerves have been so on edge for the past several months. i don't know for how long i will still have this position, nor do i know how long i want to have it! :innerconf but, anabel, my thoughts are with you because the several months that this has been going on i have just been holding my breath waiting for the other shoe to fall. i can only hope that the census will now start to rebuild, but i hope this has taught the powers that be a lesson to better follow medicare rules and regulations! i certainly don't want to see this happen again!! best of luck! :up:

curiousauntie · Jan 12, 2008

OneThunder...
No, the constitution does not give Americans, as you say, the RIGHT to healthcare. Neither does it give nursing home patients the RIGHT to hospice care.
It is interesting the way you portray nursing homes as being highly regulated with such narrow profit margins... to the point where their nursing staffs do not have time to provide one-on-one care, then eschew considering more comprehensive systems based on your political bias. Your position seems to be that if Canada cannot operate an effective nationalized healthcare system (which is highly debatable... nowhere near as simplistic as you describe) then it would naturally follow that we Americans could not do it either. Following that logic, if the Russians cannot operate an effective democracy, then neither could we Americans.
When I wondered whether hospice nurses should go into hospitals to attend the dying I was speaking about all the dying patients in hospitals, not just hospice patients placed there temporarily for either symptom control or respite care.
Your description of the narrow financial parameters within which nursing homes must operate ("FYI a profit margin of 4% is about average for nursing homes.") which then forces cutbacks in other areas ("but I have also seen those that can not keep those levels up for very long due to the cost, so, unfortunately other areas suffer, most notably dietary.") suggests that there are problems within the nursing home industry and its reimbursement system. (Also, it is not "dietary" that suffers, it is the patients.) If there is a problem in the nursing home industry then it seems logical that the best way to deal with it is within the nursing home industry... as opposed to slapping a hospice patch on a nursing home problem. That is just another example of what I mentioned earlier; i.e. layer upon layer of stopgap, quick fixes with no overall plan.
Historically, nurses did it all... the various therapies, like applying leeches, setting up oxygen, cleaning & sharpening needles etc. Little by little different specialties have come along, and of course made rules protecting their turf (a nurse can't plug in and oxygen flow meter, RT must be summoned.) Have we now reached the point where only hospice nurses can deal with death & dying? Certainly it is our specialty, but if we accept your (OneThunder's) contention that nursing home patients have a right to hospice care, then it would follow that all dying patients do as well, regardless of their location; e.g. non-hospice patients in hospitals etc. In which case, the whole hospice system would need to be re-invented.
Maybe it should be. Hm-m-m-m-m.
And whether you like it or not, some sort of nationalized healthcare system may very well be in our not-too-distant future. In which case, then what would/should hospice look like?
Michael

What both of you have failed to recognize is that while hopsice is a benifit of Medicare (and other insurances) a nursing home is the patient's HOME. It is where they live, their address. A hospital is a place one goes to (hopefully) regain their health in order to return to their home, whether it is a 2 story house in the city or a nursing home in the suburbs. No one would think of saying that a patient should not have hospice services in their home, and then say that it is because the family should provide all of same services that hospice provides and if they don't know how, then they should educate themselves and if it interferes with the care they need to give to their many children, well, then hire another person to do it. I spent 22 years working in long-term-care and sub-acute care (in nursing homes) in both for-profit and not-for-profit homes. The reality of the nursing home situation is that it IS very regulated. Every move you make, every decision you make is based on keeping to the "Regs". (and New Jersey has more stringent inturprations of the regulations then most, as the standards are above the federal standards) There are times that an LPN, responsible for medications and treatments for 30 long-term patients just does not have the time to pee or take 5 minutes to eat a meal, let along sit with a patient or their family for the extra time that a hospice patient needs. The RNs are up to their neck in madated meetings, mandated assessment forms (the dreaded MDS) mandated charting (every patient with an antidepressant, antianxiety, antipsychotic, restraint, side rail, wound, behavior issue, weight loss issue) and the RN is usually repsonsible for 60 residents. This is exactly the reason that I burned out 2 or 3 times before realizing that it was not me, but the lont-term-care system that was making me wake up 3 or 4 times a night...what did I do wrong, what did I forget to do, what has gone wrong in the last 6 hours since I left after working 12 hours (for salary!!!!!) that will bite me on the ass tomorrow. I always have had the utmost respect for the hospice nurses that worked with me, caring for my patients, who had so much knowledge about sympton relief and how to keep the dying from horrible deaths. That is the reason that I am now about to start my second year in hospice nursing. I know that I continue to bring a "long-term-care" bias to my nursing, but I also know that I am learing a lot, and have a lot more to learn.

So let's not make this a LTC vs.Hospice argument. This is about giving the person who happens to have the address of a nursing home the best care and symptom management that they can get, not about whether medicare should pay for hospice benefits to nursing home residents.

req_read · Jan 12, 2008

curiousauntie...

It is interesting to hear nursing home nurses talk about how horrible it is to be a nursing home nurse. Do you have any ideas about how it got to be that way? Any tips on how to prevent that from happening to nurses in other fields (like hospice for example.)

Michael

curiousauntie · Jan 13, 2008

curiousauntie...
It is interesting to hear nursing home nurses talk about how horrible it is to be a nursing home nurse. Do you have any ideas about how it got to be that way? Any tips on how to prevent that from happening to nurses in other fields (like hospice for example.)
Michael

Oh boy, does that put me between a rock and a hard place! I wish I had an answer for that. I dearly loved long-term-care nursing. When I started, it was before OBRA and all of the "mandates" that changed LTC to what it is now. Back then, we had the time to spend hours sitting with the dying patients, to make sure that no one died alone. To take a family member to a private place (sometime outside of the facility) and talk with them about the reality of the situation and that their mom or dad was about to take their last breath and then stay with them while it happened, while we waited for the MD to come to pronounce the patient (nurses were not allowed to pronounce at the time) and stay with them waiting for the funeral home. We also had time to spend every Saturday night with the 10 or so alert and oriented, self care patients at 9pm to watch "The Golden Girls", eating snacks that the staff brought in every week and having good times and lots of laughs!!!

BUT...

We also restrained patients routinely, with posey vests in bed with side rails up because they "might" get up and fall, used Haldol with wild abandon, did not necessarily use antidepresants enough and may have had more weight loss then was really necessary. And I worked in a defecency free (year after year) not for profit church owned facility. A LTC that was noted by the State as one of the best. So the OBRA regs were probably a good thing as many LTCs were MUCH worse. I see the problem as an overreaction to the regs by the state and also as an overreaction by the facility administration...if one piece of paper is good, 3 are better mentality. Most of the LTC nurses I know long for the "good old days", but also realize that a lot of the regulation was very necessary to keep the patients safe. I see hospice nursing as the obvious next step for my career and education. As I said, I have a lot to learn, but in the last year I have had questions about patients, especially the ones with a debility diagnosis. I am the one that at team meeting is asking why this patient is still on service, arn't they really stable, not showing a decline, arn't they ready for a discharge? I have 2 right now that I really don't feel should be kept on service, but my DPS says that we should watch them for a few more weeks.........

This is why my New Years resolution is to study, and study hard, to take and pass the certification test by the end of the year. I know I do not have the knowledge at this point to be as good as some of the nurses I work with (who have 20+ years in hospice) and who's brains I pick constantly. I have wanted to do this work for many years and have felt that hospice nurses are the heros of nursing. What we need to do is make sure that we follow the regs as stated by Medicare, that we are not pushing too hard at the gray areas that will surely get us over regulated as LTC has been. HOW???? I really do not have the knowledge to say...that is why I read this forum, to try to get some of that knowledge from all of you!!!

LaRN · Feb 6, 2009

Originally Posted by req_read

"Using hospice for something other than what it was intended damages hospice in the long run."

well the nsg homes use us for supplies. and speaking of supplies, here lately I've been feeling more like a delivery driver.

rngolfer53 · Feb 7, 2009

Originally Posted by req_read
"Using hospice for something other than what it was intended damages hospice in the long run."
well the nsg homes use us for supplies. and speaking of supplies, here lately I've been feeling more like a delivery driver.

Don't forget that many nursing homes use hospice for staff, so their employees can get their sleep during the night shift. :angryfire

OneThunder, BSN, RN · Feb 8, 2009

anabelrn...
onethunder...
your attitude is condescending and sarcastic (and yes, angry too) while your perspective is hopelessly biased. the technique of inserting red text into my posts seems calculated to give the impression of providing comprehensive responses. despite appearances however, many of your responses are defensive, evasive and fragmentary (not to mention, condescending, sarcastic and angry.)
had i seen this when it was posted, i would have replied then. at any rate, it just occurred to me that you have been using this forum as a soapbox for your political views. while normally, i couldn't care less, however, since you see fit to insult and name call, i guess i hit a nerve.
regarding the issue of why nursing homes are so heavily regulated...
that did not come to pass by accident. the director of medicare did not wake up one morning and think, "i know... let's go out and try to make life difficult for the nursing home industry." neither was it a simple matter of medicare not wanting to pay, nor a result of a "game" (documentation > regulation > documentation > regulation etc.) those things have some relevance, but as secondary effects, not as primary causes.you have absolutely no idea how the nursing home industry is run, that is very evident by your responses. in fact, the reason why my explanation is correct is the fact that medicare is running out of money (that along with social security is the ultimate ponsy scheme) and their reaction to checking the "spread sheet" and finding out that they are paying out for a high number of_______________(fill in the blank) does indeed lead them to discontinue paying for it. most of the time it happens with drugs. medicaid does it also. it is reminiscent of the old shell game. the official name is "therapeutic interchange".
the nursing home industry has a long history and reputation for bending the rules. when that happens, medicare tightens the rules. it is not that they don't want to pay, it's more a case of - they don't want to get fleeced. despite your casting aspersions on the nursing home industry, they are not the source of most of the medicare fraud.
durable medical equipment, infusion therapy,and home health agencies top this list. from the government website:
http://www.hhs.gov/medicarefraud/
but eventually hospice was accepted and settled in... and then the business people in hospice started eyeing the nursing home industry. the nursing home industry was being squeezed (largely of their own making) and needed help. hospice business people saw a golden opportunity and began pressing for the chance to avail themselves of it. eventually they got the go-ahead to start providing care in nursing homes (as opposed to assisted living homes.) and now we are seeing the result (as in the case of anabelrn above.)your spin on how hospice began in the nursing home is entertaining. be that as it may, it boils down to the medicare eligible person is entitled to the same services whether they reside in a private home, a group home, independent living, assisted living, or a nursing home.
in that sense, the nursing home industry is rather like an old inner-tube, covered with patches. you might also say it is like a drowning person. when the lifeguard (hospice) swims out there to help, the first thing to remember is that they could take you down with them.
to paraphrase a commercial, today this isn't your grandfather's nursing home. the condition of the residents that go there now are reminiscent of a hospital step down unit, complex dressings, vents, traction,and post cardiac. skilled medicare residents receive physical, occupational and speech therapy. the goal is to return function and go home if they can. most hospice patients in a nursing home are the skilled medicare residents who continued on their downward decline. others are medicaid residents who, after living in the nursing home for a period of time (sometimes years) have their chronic illnesses begin to take over. either way, if medicare pays for a person to have specialized services, it does not matter where they live. medicare does not pay room and board(except for a short general inpatient-for which they have to meet criteria or respite that is of limited duration) so it is the service of hospice that medicare is paying for, just like they pay for the therapies.
.
few would argue that the healthcare reimbursement system (or lack of one) needs a major overhaul. even healthcare itself, when motivated purely by profit, tends to get a little twisted. note for example the plethora of advertisements by pharmaceutical companies on television, many of which are prime examples of: first, convince them they have the disease, then sell them the cure. in our current system, convincing people they are sick is a lucrative business.pharmaceutical companies are a whole other discussion, and i agree. i hear the doctors say, "they must be running the ____________(fill in the blank) commercial, i have had x amount of patients ask for it this week.
and finally, i recommend watching the movie, "sicko." yes, it is slanted towards the director's perspective... but certainly no more than (if as much as) onethunder's. well, if i had my doubts before, i don't now. most certainly it's the soap box thing.
michael

if indeed, my perspective is 'hopelessly biased", then your perspective is punative.

LaRN · Feb 10, 2009

I work for what was formerly a large hospice (250-300 patients). Within the last 4-6 months, we have dropped over 100 of our patients due to a medicare probe...i.e. investigation of non-cancer diagnosis patients. We were told the LOS for most of our non-cancers was too high and so the powers that be have been discharging patients left and right due to being no longer hospice appropriate. Claims are being denied. This has resulted in major staffing cuts, etc. Has anyone else out there experienced this? Please give any details you know. I'm rather concerned for my job at this point. Didn't think I would ever be worried about my job in nursing!

I am not the officianada on the matter, but this is just what I remember. I may be wrong or outdated in my thinking:

I'm not sure if things are the same in hospice medicare reviews, but in home health medicare reviews, being chosen for a medicare probe is mostly luck of the draw (a bad luck draw too). Even an agency that is running top notch and trying to follow the rules can suffer a moderate financial hit under their reviews which can be downright tricky. If you are working for an agency that doesn't have it together......this can be a deadly blow. If the first few batches that they review don't have too many errors or problems, they usually ease up. (they don't like wasting their time reviewing good claims). But....If there are plenty errors and problems within the first few they review, you are IN FOR IT. Medicare picks up right away that you don't know what you are doing. Don't know how the reviews work now, but they used to request all visit information (documentation) from all disciplines for a particular billing cycle or two. So....make sure all t's are crossed and I's are dotted, don't send in foolish looking notes, such as: nurses notes that say patient isn't walking and aide notes that say pt is ambulatory with walker, visits times exactly the same for a social worker visit and nurse visit or aide visit, unless your notes reflect a reason for doing so. Nurse visit at 9 am that says pt had bowel movement that day, and at 1 pm same day nursing assistant visit states no bowel movement for 3 days. Nurse documents poor appetite on pt with debility dx, and nursing assistant documenting good appetite- not too bad if just a couple times, but if its the common theme, somebody is either lying or not doing their job and who do you think that is? Social worker visits that say pt is confused and disoriented and same day a nurses note indicates pt oriented x 3 and alert with teaching done and good understanding by patient noted. Nurses notes that reflect social problems such as inability to pay for medications, lack of proper care being given by family, and NO social worker consult or visit OR inneffective and useless social worker visit with nothing done or even attempted. Maybe I'm off the mark and things aren't looked at like this anymore, but it used to be the norm.

I know how to give nursing care to my patients, but as far as proper documenting on disease process I am out of the loop and would like to know more on that.

Also, I would like to know, what is the proper ratio of patients with cancer diagnosis to those with other non-cancer diagnosis? Is there some type of percentage that needs to be adhered to or is it just that a low number may indicate problems with types of patients being admitted?

feel free to correct me, red letter or not (lol). I don't have all the answers, heck, I barely know all the questions.

Thanks Michael for a simple explanation of the cap system.