Dear Ms. Smith,

After our long relationship as consultant and client, please know that I care for you and Mr. Smith and your business. Otherwise, I would not have gone through this much effort to draw your attention to a situation that I consider critical to your agency’s survival. I would ask that you examine this document very carefully, try to separate facts from feelings, and take action.

I am deeply concerned for the well being of your home care agency. I have been representing you before your RHHI and the ALJ but I can no longer do so if your slow, progressively terminal condition is left unchecked. Apparently, my representation has been welcome as a cure to your problems but my recommendations for future prevention have not been heeded. You are at risk for yet another post payment review but my attempts to head it off have been repeatedly thwarted.

For the past two years, I have been begging you to make changes in the way in which your nurses and therapists document patient care. My recommendations are based upon various decisions handed down by the ALJ on your payment denial cases. I must begin to sound like a broken record. In spite of my urgings, I have seen no improvements. Whether this is due to a refusal to change documentation practices or inability to change them really does not matter. The harm on its way to you will be the same.

When I have addressed this with your Director of Nursing, she becomes defensive of her clinicians and, at times, displays a rather arrogant attitude in a “what do you expect me to do about it” tone. She appears to be afraid of hurting clinicians’ feelings or losing them to another agency. Considering the number of payment denials due to inadequate documentation with which you have been plagued, I am not certain losing certain ones of them would be a net negative development. If they refuse to learn proper documentation habits, perhaps you are better off letting them work for your competitors.

I do not believe your administrative team fully appreciates the changing conditions under which we currently engage the court, nor are they taking these changes to heart. If further ignored, this situation will lead to significant financial pain; there simply is no other direction for it to go.

You know that Medicare has established standards. I do not understand why, despite my repeated pleas, your clinicians and contractors are not meeting those standards. I have detected an attitude among your clinical staff that they believe their practices are in line with “what other nurses and therapists are doing.” This is a dangerous attitude since they are not acquainted with nurses outside their immediate geographic and cultural community.

There is a vast difference in clinical practice and commitment to practice from state to state and region to region. Not only do the judges who decide your payment denial reversals know this but they have lately been moving around. I know of at least two ALJs who have recently moved from the Midwest to your region. When they look at your charts, they measure you by what they are accustomed to seeing from other parts of the country, not on “what other nurses and therapists are doing” around here. Fair or not, this method on the part of all ALJs is becoming increasingly prevalent; they are not persuaded by the argument that what they see in your charts is common practice in this area.

As an example, we recently lost a payment denial case with which you are quite familiar. You told me I could have and should have won it for you. The ALJ agreed that the patient needed all of the care you provided but noted that the nurse’s practice of doing “checkbox charting” was fully insufficient to show what actually took place during each and every patient encounter, or any other compelling, convincing reason to pay for the care provided.

This judge almost begged me for a reason to pay you. All we had to offer was the chart the judge already had, and I had to agree it was seriously lacking. Imagine how frustrating this is! I was prepared to argue further but slick talk and lengthy briefs will never replace comprehensively composed clinical documentation.

Expect scenarios like this one to become the norm. Judges themselves are being reviewed on their decisions and must answer to their superiors just as we answer to ours.

Likewise, I myself am judged by my cumulative appeals success record. Your agency’s consistent failure to provide me with thoughtfully and comprehensively composed documentation when I go to court for you places me in a precarious position. I incur great responsibility in defending you yet am left in a position fully out of my control, one with the potential to defame my reputation as a successful appeals consultant. I am able to provide recommendations that would strengthen your agency but my recommendations are brushed off and ignored.

This is not merely uncomfortable for me. It is untenable. It leaves me crippled in my efforts to successfully defend your claims. Therefore, I must notify you that I am suspending my services until this can be resolved. If the situation cannot be resolved, permanent termination of services is the next step.

I do not make this decision lightly. You are aware that your retainer makes my house payment each month and for this I am grateful beyond words. However, I cannot in good conscience continue to take your money, knowing you do not have plans to rectify the situation.

Your clinicians need training and they need discipline. If you like, I can recommend a number of training programs and clinical consultants. I strongly advise you to engage one or more of them. Perhaps, after all of your clinicians improve their documentation skills, we can discuss my return as your appeals consultant.

I am sorry if this sounds harsh. If you know anything of me, you know I always speak my mind, whether what I have to say is popular or not. That is my job and I take it with greatest seriousness.

To help you deliver this message to your staff – and I hope you do – I have attached some specific examples of the kinds of documentation issues I have received from you and have had to present to various judges. Perhaps this can become the beginning of your training effort.

Sincerely,

The letter concludes with the consultant’s signature and an appendix with concrete examples of the agency’s documentation style, along with detailed explanations of what is wrong in each example. We reprint that appendix under a separate headline: “Real-world Examples of Documentation That Will Result in Payment Denial.”

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