If Regional Home Health Intermediaries (RHHI), Qualified Independent Contractors (QIC) and Administrative Law Judges (ALJ) have the power to declare a home health patient has been serviced based on a “Medically Unbelievable” or “Medically Unnecessary” assessment, well-meaning, professional home health care nurses and administrators should have the corresponding power to declare such a decision a “Medically Unbelievable Denial” (MUD).
This regular feature of the RAC Assistance for Home Care report will present the facts of cases we find and allow the reader to decide whether the government’s decision was justified or CLEAR AS M.U.D.
(Editor’s note: Please be assured that this newsletter’s reporters and editors receive no personally identifiable health information from their sources. All reports are de-identified before we receive them from home care agencies that volunteer them to us. We then triple-check them for HIPAA compliance before publication.)
The patient:
There was never a question that this Congestive Heart Failure patient was homebound and eligible for the Medicare home health benefit. If the Stasis ulcer on her leg was not serious enough to keep her mostly bedridden, her 103-year old, failing heart certainly restricted her ability to get out and about without “considerable and taxing effort.”
The wound was initially measured to be 8.8cm x 4.5cm with 55% necrotic tissue surrounding the wound bed. At the end of a 60-day Medicare payment episode, a second assessment found it to be 6.5cm x 3.5cm with 25% dead tissue. Thus, with her physician directed, home care agency treatment proven effective, the patient’s case manager was able to decrease nursing visits from daily to three times per week approximately halfway through the 60-day PPS episode.
Wading through multiple denial levels
Following payment denial by the agency’s RHHI and confirmation of that denial by the QIC, the agency appealed to the ALJ.
There, the honorable Wanda Zatopa, of CMS ALJ Corps Region Nine, found that the agency “failed to satisfy the requirements for the home health services provided to the Beneficiary in accordance with 42 C.F.R., paragraph 409.42 and the Medicare Benefit Policy Manual, Chapter 7, Sections 30 and 40. Here, although the medical records reveal that the Beneficiary was confined to her home, was under the care of Dr. [Name] at the time the services were rendered, and received the services under a plan of care established and periodically received by Dr. [Name], there is no evidence which indicates that the Beneficiary was in need of skilled nursing care on an intermittent basis or that the care she received was skilled in nature.”
Judge Zatopa’s decision went on to note that the agency’s testimony claimed that wound debridement, with gauze and wet-to-dry dressings, was the skilled nursing procedure responsible for the wound’s significant healing progress. She countered, “the daily skilled nursing notes submitted on behalf of the Appellant fail to indicate that such a skill was performed, and furthermore, there is no documentary evidence to show that the Beneficiary’s treating physician ordered any such debridement as part of the Beneficiary’s wound care regimen.”
Finally, the agency’s representative explained to the judge that, in addition to debridement, nursing staff also cleansed the wound site with a saline solution and applied Silvadene or Aquacel cream. Zatopa’s response, “The ALJ finds that this wound care regimen is a pretty standard way to treat such a wound and accordingly the services provided by the Appellant are not skilled in nature.”
Agency arguments that the 103-year old CHF patient did not have family or friend caregivers available to perform such unskilled care did not sway the judge, who stated that it makes no difference whether a patient is 16 or 90 years old. In spite of testimony that the patient’s bandages were completely saturated by bodily fluids every 24 hours, she asserted there was simply no justifiable reason to perform daily visits during those first 30 days.
According to the appellant agency’s court representative, judge Zatopa went one step further than merely denying payment. Implying but not overtly stating that she suspected the agency performed the daily visits solely for the purpose of driving the episode into the PPS Outlier category, she ordered the agency to produce all of its supply billing records for the episode.
The result: Medicare home care services for this patient, at a cost to taxpayers of approximately $65 per day, have been replaced by institutional care, at roughly four times that cost to the government.
The agency and its consultant have begun to plan the next step, appealing the case to the Departmental Appeals Board. Watch future “Clear as M.U.D.” columns for a follow-up. When submitting comments on this story, please reference “Clear as M.U.D. 2009-001.”
