ID agency’s review prevents fraud, abuse
Home care quality managers have long have claimed that most of the so-called fraud and abuse problems discovered in Medicare claims are really the result of unwitting errors on the part of home care staff.
This means it is more important than ever that quality managers develop a chart review process that’s designed to identify and correct those errors before they are submitted as claims.
Gritman Home Health in Moscow, ID, has developed a chart review process that serves this purpose. Already, it has found some errors that Medicare would have labeled "fraud," says Pat Lucker, RN, quality manager.
For example, the chart review process has discovered a few simple errors that were caused by a billing employee keying in the wrong dates or a field staff worker writing down the wrong date on the daily chart.
"I check the note against the billing, and if there is a discrepancy there I point that out so we’re not billing for a day when a visit isn’t made," Lucker says. "It’s ridiculous, but they put people out of business for those types of mistakes, so it’s a very real threat."
Some other examples of errors included instances where a home care aide arrived at a patient’s house solely to give the patient a shower, and the patient refused the service. Although the home care completed documentation that said the patient refused the shower, somehow the documentation was filed as a billable visit, Lucker explains. "But it wasn’t a chargeable visit, since the shower wasn’t given and the patient refused any kind of personal care."
Capture lost revenue
The chart review process also has uncovered nursing and therapy visits that were made and documented, but not charged, thus giving the agency some income that otherwise would have been lost.
Here’s how the chart review process works:
1. The quality manager reviews an entire case file. The case file contains all that has been filed by the staff, along with physician orders and nursing notes. Lucker pulls out a chart review tool and uses this to checklist everything she will review in the file. In all, Lucker reviews 50 charts a month, which takes her a total of eight hours, spread over two or more days. Since the agency is small, with only 700 to 800 visits a month, she is able to review all the charts.
2. Check billing charges. Lucker checks to make sure the Medicare 485 form is signed and dated and submitted within the 30-day time limit. The review process also includes checking all verbal order documentation to make sure those are signed and dated, especially when they’re pertinent to treatment or change of discipline or visit routine. Then, she compares the field staff notes to the charges, again checking dates to see how many visits were made each week.
3. Check medication profile, lab report, and supplies. Lucker looks at the patient’s medication profile to make sure it’s updated. While this paperwork is out, it’s also an opportune time to make sure the physician’s order has been copied and included with the update.
Next, she’ll check to see if the lab reports are included on the chart that month. Again, this means checking the doctor’s orders to see what has been ordered, and then looking at the nursing note to see the date it was done. If any charts are missing this information, Lucker will print it out to show the nurse.
Also, Lucker will check whether the patient’s supplies have been charged and documented on the nursing note.
4. Check nurse’s aide care plan. The chart review process includes making sure the nurse’s aide care plan is followed, with supervisory visits made every 14 days according to regulatory requirements. Lucker allows a little leeway in this area. "They say every 14 days, and that’s really difficult sometimes, and if we get a little out of whack on that I can’t do anything about it because there are times that nurses can’t get out there or want to go later in a week," she says. "It might be 16 to 17 days."
5. Confirm homebound status. The chart review ensures that nurses are documenting the patient’s homebound status, using the four-pronged approach on the OASIS assessment tool. They must ask and answer whether a patient has a breathing problem, a problem with locomotion, a problem with transportation, and whether the patient can leave the home to do the shopping.
If nurses have answered those four questions correctly, then the homebound status is met. If the nurse has had difficulty determining homebound status based on those questions, then agency rules ask them to consider whether the patient has a normal inability to leave the home. "For instance, does the patient’s leaving the home require a considerable and taxing effort, and are absences from the home infrequent and of short duration?" Lucker explains.
6. Check the billing preliminary report. The agency has a worksheet that includes all of a patient’s charge information for a month. Toward the end of the month, Lucker audits this report to see whether the frequency of visits is appropriate, that skilled care was provided, and all physician orders were followed.
Again, this includes checking skilled care services and orders against what was billed. And all of this is briefly checked again when the final billing report is issued.
7. Note all problems on chart audit tool. Lucker jots down notes about every discrepancy or problem she spots in the chart. She also records potential red flags. For example, if the Medicare 485 form is not in the chart, but a copy of it is in the chart, she’ll note that the 485 is a copy.
"If there’s nothing on the chart to indicate the 485 has been started or done, I write zero’ so I know how to make sure the 485 is at least in the works and hasn’t gotten lost somewhere along the line, which sometimes can happen."
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