The Business of Home Health

hoolahan, ASN, RN · Jan 26, 2004

You poor thing! First may I say that is BS that you don't get paid. I would march right in there and tell them you will only make re-visits from now on if you will not be paid for your time and/or mileage. Technically, you can claim this mileage NOT reimbursed by the agency, on your income taxes, but you shouldn'y have to, that is BULL! It makes me SOOOOO angry when agencies abuse their staff like this! This is exactly why so many good nurses leave home health. There is enough stress w/o this crap. [/end rant]

Anyway, to answer the medicare question. I have never been able to get a straight answer for this. I have been unofficially told that we do not get Medicare Reimbursement for an Eval only visit, if the case is not opened to service. ie, you get a referral, you go out, and the only thing the pt really wanted was a HHA. They have no skilled needs whatsoever. Or, they are not even homebound. You cannot open that case under Medicare. So, you eval'd and chose not to open case.

Conversely, there is the "One and done" in which, the pt is a post-op CABG, who went to rehab afterwards, and have 1-2 new meds, but incisions are well on their way to healed, the pt family is completely knowledgeable about their meds, they hire a private CG to be w dad, who reminds him to take his meds daily, and beyond ensuring the home is safe, vitals are stable, and assessment is done, you do not see any further SN needs for the pt, this is, from my understanding a reimburseable visit.

In other words, you did teaching, there was a need, and you were able to determine that b/c the family had it completely together, and has their own BP machine and check it every day, etc..., you will not be needed for more than one visit. This visit is billed as a Low Utilization P--- A--- , or LUPA, I forget the words, but if it is 4 visits or less under Medicare PPS regs, then it is billed at a fee-for-service rate. Over 5 visits, it is a lump sum payment based on the calculation of the MO questions on your OASIS. You get more if you send PT and they make a minimum of 10 combined therapy visits also. So,even if 2 SN and 1 PT Eval are done, the agency can bill all three at the per-visit rate, if more than 5 by all, it's PPS package sum, but if therapy doesn't make at least 10 visits, then the PPS sum is paid at the lower rate for the diagnosis and MO questions score tally.

Your agency should have oriented you to this. This happens so much, and the poor nurses are stuck in the field, and have no idea how all of this works out, then get "counseled" when they make a "mistake." I worked for another agency a while back, that took the time to carefully orient all the nurses to this business, and trust me, that agency ran very efficiently, the best I have seen to date.

Your agency can NOT force a pt to have 4 or more visits. If that is their expectation, and it was your assessment that there was no SN needs, then they are commiting Medicare fraud, and you will be a party to it, so kudos to you for sticking to your guns. The pt could report them to Medicare or the state health dept, and they'd be up poo-poo river without a paddle!

At my present agency, the secretaries call all pt's the eve before to confirm new admits will 1. Be home, and 2. are homebound. Then, when the nurse calls in the am to tell them the time of the visit, she agains asks if the pt is homebound, if they have a CG to teach the wound care, etc... If they do not meet criteria, the nurse hands it to the sup, who will call the pt and explain why we can't go out. The referral source, doc, and managed care co, if applicable, is notified, and it's adios.

A lot of this starts with proper intake, esp for MD referrals. They tell pt's the most incredible things, like we'll bring the oxygen, or meds, etc...when we go out. Our intake dept carefully questions referral sources, and they expect a call before a ref is faxed, if there was no call to us, we call them, and ask if there is a CG, what exactly is the skill needed, and if pt is homebound. Of course sometimes, like in your situation, even all of those checkpoints may have had the same end result.

If your agency refuses to pay you, I would ask to speak to my supervisor and ask her about the diff between a LUPA and PPS payment, and then say, So, it's not fraud to open a case for 4 visits, even if there is no skilled need?" And bat your lashes. She'll get the drift! You would be surprised how often a supervisor or a group of them, cannot even agree on the interpretation of the regs, so she may not really understand all of it either.

When PPS first started, I went to a web site for Lifeline, and they sent a free CD education program about PPS, it was enormously helpful. But, I have no idea what the site URL was exactly, where the darn disk is to look, or even if it is still available.

I hope what I have typed here is clear, for me it is old hat, and I hope I am using lingo you are familiar with, etc...

This will make me crazy, I have to hunt down that CD tomorrow and see if I can find the website and if it is still available. Meanwhile, ask your supervisor to inservice you on Appropriate reasons for openning cases, tho you seem to already have a good instinct for this.

Good luck.

erroridiot · Jan 26, 2004

This visit qualifies as skilled. The situation is sad, because this patient needs a nurse.

The agency did not contact the patient. I find this unethical. They apparently expected me to do this. I do not feel comfortable making business or billing calls for the agency. This should be their responsibility.

This supervisor does not seem to be knowledgeable about home health. I have some limited knowledge of P.P.S. I was told not to even bother with the paperwork. To me, this is not the right thing to do. I will finish the paperwork and turn it in.

Medicare.gov has most of this vast information posted about billing. It takes hours to find what I need.

The agency has not finished orienting me. They do NOT pay for orientation time only visits. I could report them for this, but then I would end up blacklisted.

No marching back to this agency. I will march elsewhere! I think that it will be in my best interest to discontinue "working" for this agency which does not pay its employees and look elsewhere for work. I will avoid any further financial losses, phone bills, gas, mileage or time wasted "working" for this company. It was a second job anyway. I will find something else to do.

___________________

"The significant problems we face cannot be solved at the same level of thinking we were at when we created them." -- Albert Einstein

hoolahan, ASN, RN · Jan 26, 2004

I can't tell you how sad this post makes me. Sad b/c I have seen it so many times. There seems to be a lot lacking in home health orientations, and the environment does always change, so it makes things difficult to orient to. This is where the supervisor has to be there, at least by cell phone, to contact.

I will disagree strongly with you on one point. The issue of the field nurses not having to understand the biz. It is essential that you understand the biz, as it is part of the pt teaching. They have to know how to get supplies, that medicare won't provide an aide the way medicaid does, eben tho they "paid into this all my life and deserve this" and they have a pint, but of course you are powerless to change it, just have to be creative in suggesting resources to help them out.

Re this situation tho, since you did not agree w the sup, she needs to have that conversation with the family, basically, b/c she is wrong.

If this situation ever comes up again, call your supervisor from the home, explain what the family's wishes are, then if she tries this again, hand the phone to her family and ask them to have her explain the agencie's "policy." But, she will get into trouble by forcing visits on people, eventually.

Another good time is on the call before you go out, it should be the nurse making the visit that calls, and discuss what you anticipate doing, review meds, check VS, take a history, and assess specifics, like inc, etc.... I have been able to stop an inappropriate referral this way. You have to be frank with the pt's. They deserve to know what Medicare will and won't cover upfront, or even at the beginning of a visit, so you don't waste time doing a lot of unecessary paperwork. If the case is not open to service, and no hands on was done yet, we just document on a progress note why. If an assessment was done, like you did, we most certainly DO the paperwork. She is trying to justify not paying you. Can you go over her head?

Don't give up on home health, it can be great when you find the right agency!

renerian, BSN, RN · Jan 27, 2004

Wow I can see your supervisor's ploy. Rather than get paid as a LUPA (4 visits or less) she is trying to get paid for an entire episode. Huh. Definately not the correct way to approach it.

I can post more but don't want to put my foot in my mouth.

renerian

erroridiot · Jan 27, 2004

Originally posted by renerian
Wow I can see your supervisor's ploy. Rather than get paid as a LUPA (4 visits or less) she is trying to get paid for an entire episode. Huh. Definately not the correct way to approach it.

I can post more but don't want to put my foot in my mouth.

renerian

I need all the input that I can get on this dilemma.

Please post more. I'll bet that your foot and mouth will be just fine.

Just be - delicate.

CseMgr1, ASN, RN · Jan 27, 2004

Originally posted by hoolahan
Your agency can NOT force a pt to have 4 or more visits. If that is their expectation, and it was your assessment that there was no SN needs, then they are commiting Medicare fraud, and you will be a party to it, so kudos to you for sticking to your guns. The pt could report them to Medicare or the state health dept, and they'd be up poo-poo river without a paddle!

Yea, and I worked for at LEAST two Home Health Agencies that were not only put out of business, but their owners also served time in Federal Prisons, because someone got wise and reported their butts because of this type of thing.

renerian, BSN, RN · Jan 28, 2004

AWwwwww I see you worked for FAHC as well. Me too.

Okay I really do not want to say something bad about a fellow nurse in home health but on the issue of forcing you to do visits you feel are not warranted is not good. That is not something you really should do nor I could do.

The big Fr**d word comes to mind.

I hope your super does not try to make you. I would be heading for the door.

renerian;)

JennyHHRN · Feb 3, 2004

Wow, Renerian almost spoke that "5 letter word": Fr**d.

It is so frustrating and sad that home care nurses are constantly subjected to that feeling that Medicare might consider them a criminal. My agency has 3 RN's faced with criminal fraud charges. My gut tells me they did nothing wrong. The details are too long, and complicated to get into. To be honest, I'm not sure what the prosecution thinks they have against them??? The investigation began almost 6 years ago! They are still awaiting trial! Their lives have been ruined, and the worst is, if and when they are proven innocent there is no way to repair the damage this has done to them. For 6 long years our agency has been paronoid to the brink of disaster when it comes to admission criteria. The mere mention of a patient stepping one foot out of the house sends our staff into immediate discharge mode.

I try to remember first and foremost, I do what is right for my patient. I base tough calls on whether or not I can picture myself up on a witness stand swearing I was acting in my patient's best interest. I HATE THAT!

I also hate that the CMS Home Health website is so freaking hard to get specific info from. enough said....sorry for ranting...

renerian, BSN, RN · Feb 5, 2004

The best way to deal with the CMS website is to find what you want and bookmark it.

renerian

lioneliz · Feb 6, 2004

All patients (home health patients or otherwise) have the RIGHT to participate in planning thier care and to accecpt or refuse care. They have this right regardless of how much it inconvenices the home health agency.

I called my supervisor and was told to "Call them and tell them that you are making 4 more visits or we won't get paid."

This would not be a truthful statement. An agency can get paid for less than 5 visits. They just don't get as much as they wanted.

Did you contact the physician and find out what type of care and length of service he expected? Sometimes pt's/families do not understand what the physician said & sometimes they fib a little to suit their needs and desires.

My suggestion for you in dealing with the agency supervisor is to request that they put in writing how you are to respond to a situation such as this one. I bet ya they won't go on record as saying the patient has to accept 5 visits.

Good luck to ya

goodywhyte · Feb 20, 2004

I'm a little late to this discussion but, as the admit nurse for our agency, it is I who determines frequency, not someone in the office! Isn't that who should determine whether it's a legitimate admit, determine frequency, and set up the treatment plan? Sometimes docs just refer to home health because they don't know what *else* to do, or they don't really know how it works. As part of my admit process I teach the family, first, how home health works, how it's set up, what the "rules" are and etc etc etc. Not about reimbursement issues, just all that has a direct effect on them.