Archive for 'Tool Kit'

Medicare Fraud Hunter Reveals Home Health Data Mining Playbook

Posted on 06. Jul, 2009 by .

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HHAs take note: John S. Darden, a DOJ senior trial attorney who has worked the HIV infusion busts in Miami and Detroit, has revealed his to-do list, and you’re near the top.

Darden’s top 3 “hot areas of enforcement?” Infusion, DME and home health. Fresh on everyone’s minds: DOJ’s recent announcement that 8 individuals in Miami have been charged in a $22 million home health fraud scheme.

Why even up-and-up providers should care about HEAT: The infusion fraud in Miami went on for 8 years and was practically franchised before federal fraud hunters caught on, Darden explained at the recent American Health Lawyers Association Annual Meeting. While many of the criminals have been caught, Darden added, the money they stole from U.S. taxpayers is gone forever.

AUDIO: Handle fraud, whistleblowers, and qui tam actions before the government does. With home health attorney Bob Markette.

Rather than “pay and chase,” the government has learned to data mine as the health care fraud is happening, Darden told AHLA attendees. Upstanding providers should understand the billing patterns HEAT’s federal fraud hunters are looking for so they don’t get caught in the cross-fire. Darden’s list of ‘nonsensical billing patterns’ that signal fraud: (more…)

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OASIS C Pressure Ulcer Checklist

Posted on 09. Jun, 2009 by .

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Most pressure ulcer prevention and treatment tools have been developed for nursing homes, but home health agencies are about to become more accountable, with OASIS C process measures taking effect in January 2010.

Use these best practices from the quality improvement organization Quality Insights of Pennsylvania to look at your agency’s policies and processes to see how you measure up:

• Do a skin risk assessment on admission/readmission and every week x 4.

• Assess for intrinsic factors that put patients at a higher risk of pressure ulcer development.

• Assess skin risk quarterly and with change in condition.

Get a list of medications that increase the risk of pressure ulcers at this AUDIO TRAINING EVENT.

• Implement interventions related to skin risk assessment.

• Develop policies, procedures, and protocols consistent with current standards of practice. (more…)

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RACs March to Home Health: 4 Ways to Prepare

Posted on 28. May, 2009 by .

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RACs aren't child's play

RACs aren’t child’s play

There’s no question about it. The Medicare program’s Recovery Audit Contractors are armed and ready to sweep the greater medical community, including home care providers.

In their three-year pilot, RACs racked up a whopping $1 billion in corrected overpayments, and they’re not stopping there. These medical review bounty hunters are rolling out in 24 states now and will start activities in the remaining states in August.

If you’re submitting claims to Medicare, it’s 100 percent odds that you’ll be audited,” cautions Tim Johnson of Castle Rock Medical Group, a Denver-based consulting firm that specializes in RACs. It might not happen right away because the contractors will target high-dollar claims first. But as they become more efficient, “the lower they’ll drill down,” he says.

AUDIO TRAINING EVENT: Attorney Robert Markette reveals the home health hot spots RACs are looking for.

Experts recommend these tips for home health agencies looking to minimize RAC review fallout:

1. Act fast on record requests. If a RAC contacts you with a medical records request, you have 45 days to submit your data, or you get an automatic denial, says Linda Baumann, attorney with Arent Fox inWashington, D.C. “It may sound like a lot of time, but a lot of people are missing this.”

This task might become even harder when your staff is faced with requests from unfamiliar contractors in unfamiliar formats.

Looking ahead: “Make sure that you have all of your processes in place and all of your documentation in order so that if auditors are addressing issues you don’t feel are substantiated, you’re ready for the appeal process,” counsels attorney Cherilyn G. Murer of Murer Consultants in Joliet, Ill. “In these early days, the appeal process is critical; this is the time to be aggressive with the audit and with the appeal because we’re setting the stage at this time.”

2. Give your documentation practices a makeover. This may take re-education, but it’s well worth the time. “You have to…over-exaggerate documentation relevant to medical necessity,” Murer stresses. “We’ve always said documentation is important, but right now it is at the essence of our survival.” (more…)

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Hospice Eligibility Documentation Checklist

Posted on 28. May, 2009 by .

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The best defense against auditors, surveyors, and even fraud investigators hanging their hats on hospice eligibility issues is comprehensive documentation by your clinicians.

In addition to the patient’s vital signs, the patient’s record should include these types of clinically measurable data points that show the patient’s decline is consistent with a six month or less prognosis,according to consultant Joy Barry with Weatherbee Resources in Hyannis, Mass.:

• Body mass index

• Mid-arm or mid-thigh circumferences

AUDIO TRAINING EVENT: Secrets for enforcing documentation excellence, with attorney Mary Michal.

• Palliative performance scale scores

• Functional assessment staging scores

• Infection history

• Physician office or emergency room visits

• Increasing levels of caregiver support with activities of daily living (ADLs)

• Increasing frequency of hospice visits, changing medical equipment, or medication-related needs.

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