Stamford, CONN. – August 1, 2011 – IVANS, Inc., a national health information exchange, announced Monday that 73 percent of hospitals agree that the Recovery Audit Contractor (RAC) Program helps to reduce Medicare fraud and errors.

However, more than 60 percent do not think the audit process is fair.

According to IVANS 2011 RAC Audit Survey, respondents cited that the extra time and money it takes to substantiate a RAC claim is impacting budgets and resources that are already stretched too thin, and that the frequency (every 45 days) with which they can be audited is burdensome to their administrative workflow. The study also revealed that hospitals believe the review process is too subjective and they need education on how to reduce future audits.

“IVANS survey demonstrates the need to ensure that these programs, which are valuable in their end results, are not too burdensome for providers,” said Clare DeNicola, IVANS president and CEO. “Using automation to streamline the workflow can help reduce the administrative challenges providers are facing with these audits.”

In this instance, CMS appears to agree. The government agency that manages the Medicare program and contracts with the four collection agencies to provide recovery audits recently implemented the “electronic submission of Medical Documentation” (esMD) program. It enables Medicare contractors, such as RACs, MACs, CERTs and PERMs, to accept electronic attachments from providers, a significant timesaver over printing and delivering many pounds of paper via fax or overnight courier.

IVANS is one of the CMS-approved Health Information Handlers (HIH). It offers a gateway, IVANS LIME™ AuditDocs, that conforms to Nationwide Health Information Network (NHIN) standards and leverages a web-based health information exchange (HIE) portal. A tracking feature confirms when documents have been received by an auditor and a document archiving function keeps each document set available throughout the RAC appeals process.

An IVANS news release underscored the importance of filing appeals and following them through the lengthy process, citing a 64% appeal win rate during the 2007-2009 RAC demonstration.

The IVANS survey also found:

Many home health care and hospice providers are understandably concerned with the tight deadlines required by Medicare auditors for submitting medical documentation to support an audited claim, especially considering limited available time and the financial impact of adding staff. Now that ZPIC activity is accelerating and some of the RACs have added home care language to one or two of their CMS-approved
audit issues, forward-thinking agencies will investigate CMS’s esMD program and evaluate software companies ready to help them use it.

The IVANS survey was conducted electronically from June 7-22, 2011, and the results represent responses from 128 hospital providers across the United States. A full summary is available. Write to Cecile.Locurto@ivans.com.

www.ivans.com

Co-sponsoring the effort will be the National Association for Home Care & Hospice (NAHC), the Home Health Quality Improvement (HHQI) National Campaign, the Forum of State Associations and Fazzi Associates, a national best-practice research firm, which will manage and coordinate the study. Additional national groups are anticipated to co-sponsor or support the effort.

“Re-hospitalization is one of the most critical issues affecting quality scores and overall credibility of homecare agencies, not to mention patients themselves,” said Keith Crownover, Delta president and CEO and chairman of NAHC’s Home Care Technology Association of America (HCTAA), “and agencies are under incredible pressure to reduce their hospitalization rates. We are extremely pleased and excited to be a sponsor of this study, and believe it will have a positive impact not only on homecare agencies but on our nation’s healthcare industry as a whole.”

The study will be overseen by a National Steering Committee made up of sponsors and key agency leaders from each region of the country. An initial report of findings and recommendations will be presented at NAHC’s 30th Annual Meeting in Las Vegas. A complete study report and webinars will also be provided at no cost to all home care agencies beginning in late October.

Each year, millions of patients are discharged from hospitals, only to end up being readmitted. A recent study by the New England Journal of Medicine found that 20% of fee-for-service Medicare patients are readmitted within 30 days of discharge, and 34% return to the hospital within 90 days, often due to unclear discharge directions or lack of follow up communication with their caregivers. Medicare is responding by paying reduced fees when a patient is readmitted for the same condition. The cost of avoidable readmissions to CMS is estimated at approximately $17.4 billion.

According to NAHC, since the inception of Home Health Compare, average home health 60-day re-hospitalization rates nationally have hovered around 29%, while at the same time, more than a quarter of all agencies have scores of 25% or lower. “Obviously, many home care agencies have developed expertise in keeping readmissions to a minimum,” adds Crownover, “but the goal in this study is to uncover exactly what practices tend to work best and share the findings with the entire industry. Even a 2% difference would result in reducing over 63,000 hospitalizations at a net savings of $0.5 billion.”

Headquartered in Altoona, Pennsylvania and a leader in the homecare software industry for more than 40 years, Delta develops specialized solutions and services for homecare, hospice and private duty agencies. The company previously sponsored the National OASIS-C Best Practice Study and the National Excellence in Therapy Project. The latter studied the appropriate levels of homecare therapy services and published best-practice guidelines, which the company incorporated into its latest software tool, ClinicalVirtuoso™, built collaboratively with almost 20 therapy organizations and currently available to the industry.

www.DeltaHealthTech.com

Lost revenue and poor compliance go hand in hand. They infiltrate a home health care agency together. Managing revenue cycle means improving compliance as much as it means ensuring complete and accurate billing processes and A/R follow up procedures.

Compliance is the responsibility of all staff, especially those with clinical and financial responsibilities. In today’s Medicare environment — and it is not much different if a provider’s primary payer is insurance or the patient — mere automation is insufficient. Quality Revenue Cycle Management (RCM) processes are required today more than ever.

In fact, RCM is the number one key to meeting today’s home health compliance challenges. Considering the current regulatory environment, where we are seeing sharp increases in ADRs, the imminent rise of collection agencies such as Recovery Audit Contractors, and intensive, relentless MAC, MIC and Z-PIC audits, home healthcare processes and systems dare not fall short of the challenge.

RCM processes must build in compliance, not treat it as an afterthought or a luxury. Patient care is a complex proposition. Building in compliance requires that communication and interdisciplinary coordination are part of a plan of care that manages a patient’s medical needs. There are four key components to the process of building compliance into a plan of care:

• technology
• documentation
• coding
• billing

These four business pillars support RCM and form a foundation for compliance. Think of RCM as permeating the entire life cycle of a patient care episode, from referral to assessment to plan of care to patient record and finally to the revenue derived from that care. When a plan of care is carefully developed and managed through compliant systems and processes that all talk to each other, a complete management cycle results. When done right, the benefit of this cycle is that it provides the agency with a comprehensive, dynamic, profitable, accurate and compliant home healthcare business.

Most importantly, it results in the ability to provide the highest possible level of patient care,
making the agency the first choice among doctors, hospitals and care planners.

Technology only part of the answer

In order to achieve compliance in the contemporary regulatory environment, home healthcare providers must employ more than just point-of-care technology and a centralized billing/coding system. It is imperative to utilize the RCM processes in order to verify assessments, review clinical processes and reconcile resulting data as part of compliant revenue generation. Incorporating RCM processes as part of an overall business strategy often results in improved reimbursement, bullet-proof billing compliance and stellar clinical outcomes.

Lost revenue and poor compliance go hand in hand because OASIS and coding errors are often the result of incomplete and incongruent assessments. Billing mistakes typically occur because visit activities vary from physician orders. Data errors are frequently triggered by hurried keying into point-of-care and EMR systems. A well-developed RCM system as part of operations, implemented in real time, can mitigate most of these costly mistakes.

With compliance comes control and peace of mind. Compliance leads to more positive patient outcomes, fewer hospital readmissions, more retained revenue, greater efficiency and more predictable cash flow, while providing the business peace of mind that comes only when patient outcomes match plans of care. A home health agency’s business depends on the quality of patient care provided. Doctors, hospitals, and care planners need an agency they can trust to deliver quality care and outcomes, period.

What RCM is and is not

RCM begins with a complete data capture and error mitigation philosophy impacting every staff member and virtually every aspect of a healthcare provider’s business operations. This includes:

• accurate patient assessments, the cornerstone
• correct OASIS documentation
• clean patient data
• physician order monitoring
• visit reconciliation
• clinical coding with review
• QI oversight
• A/R management and collections follow-up

Systems must be designed into processes that identify errors prior to revenue generation. Catching up with after-the-fact chart audits is no longer an adequate process in today’s environment. Operations must have built-in processes that catch incongruence in real time while it is occurring…not after the bill has flown out the door.
RCM systems monitor all administrative and clinical components that contribute to the capture, management and collection of patient service data.

The heart of the RCM process is a team of specialists charged with the responsibility of establishing and implementing policies, procedures, and performance measures and standards.

RCM begins and ends with clinicians

In order to obtain compliance within the RCM process, coding accuracy is indispensable. For the average home healthcare agency, however, achieving the necessary level of accuracy on a consistent basis is often an impossible dream. Among the most prominent roadblocks to coding success is the speed with which codes change. Dozens of alterations take place each year, seemingly in the blink of an eye.
In 2009 alone, a total of 290 new codes were established.

Coding errors create even more vexing challenges, the majority of which are related to documentation accuracy and completeness. Co-morbidities are missed during this phase, opening the floodgates to improper sequencing and inaccurate primary diagnoses. Clearly, RCM must begin with management’s confidence that assessments are accurate. Crucial to this phase are clinical tools. It is management’s responsibility to assemble the tools — especially comprehensive and ongoing training programs — that will properly channel the critical thinking skills required and expected of field staff.

Then, even with confidence in your staff’s coding and documentation skills, ensure excellence by assigning RN coding experts to review every assessment to see that every plan of care reflects best use of ever-changing codes and regulations.

Accurate and compliant coding is not only the image of your standard of care that you broadcast to the community. It is the cornerstone of your ability to receive and retain revenue. Getting it right is the best way to grow your business and increase patient and doctor satisfaction with your plans of care.

Cliché though it may be, there is a bottom line to consider here. Management’s focus on strong patient outcomes through compliance means greater revenue retention and the lowest audit risk. Clearly, effective RCM is a timely solution providing agencies with a foundation for a vigorous bottom line, a solid grip on financial activities, freedom to focus on priorities, and a welcome relief from compliance anxiety.

Ed Buckley is CEO of Select Data, a home care software and clinical services company based in Anaheim, California. He welcomes comments and can be reached at ed.buckley@selectdata.com.

Payment denial/appeals consultant has urgent message for Medicare providers

Partners 7th Annual Connected Health Symposium

The Way Forward: Reform’s New Focus on Health and Wellness, Independent Aging, Chronic Condition Self-Care and the Tools That Support Them

On October 21-22, The Center for Connected Health, a division of Partners HealthCare, will invite the future-oriented healthcare community to Boston to discuss ways to move care beyond the hospital and into the day-to-day lives of patients. Topics will include healthcare payment reform, provider accountability, system gridlock, patient self-management, available technology tools and the role of IT executives.

The 7th annual Connected Health Symposium will be a two day affair plus pre-meeting workshops at the Boston Park Plaza Hotel & Towers. Featured speakers will include:

• Caroline Apovian, MD, FACP, FACN, Associate Professor, BU School of Medicine; Director, Center for Nutrition & Weight Management, Boston Medical Center
• B.J. Fogg, Director, Persuasive Technology Lab, Stanford University
• Gary Gottlieb, MD, MBA, President and CEO, Partners HealthCare
• Sheena Iyengar, Inaugural S.T. Lee Professor of Business, Columbia Business School
• Cory Kidd, MS, PhD, Founder and CEO, Intuitive Automata
• Thomas Lee, MD, Network President, Partners Healthcare System; CEO, Partners Community HealthCare
• Geoffrey Ling, MD, PhD, Revolutionizing Prosthetics program, DARPA;  Professor and Vice-Chair of Neurology, Uniformed Services University of the Health Sciences

www.connected-health.org

Payment denial/appeals consultant has urgent message for Medicare providers

“How ZPICs and PSCs Monitor Your Agency: An Insider’s Look” is the title of a traveling two-day seminar that will stop next in Houston at the end of August. It will be presented by former nurse and former California OASIS coordinator Michael McGowan, who has spent more time arguing against payment denials in front of Administrative Law Judges than most attorneys, and with a 90% success rate and over $38 million recovered for clients.

Billed as “Tools, Tips and Methods to Avoid Overpayments and Audits,” the seminar offers practical steps to manage the data you supply to the government so that it cannot later be used against you.

Today, state and federal contractors are targeting home health providers in a handful of metropolitan areas known for high rates of fraud. Honest providers prone to sloppy work or simple errors are being treated the same as those who purchase or start home care agencies with unabashed criminal intent. Soon, these fraud abatement efforts will spread nationwide after ZPICs and PSCs gain their experience in Miami, Los Angeles and Houston.

The course covers two intensive days from 9:00 am through 5:30 pm. A promotional flyer proclaims, “Take action and build a strong defense. Eliminate the guesswork. Start running a safe, profitable, trouble-free business. Learn exactly what practice patterns get you flagged for audit and what to do about it.”

Course tuition is $525 in advance and $599 at the door but McGowan will waive 100% of the fee for any agency that can pass his Post-Payment Mock Survey. Other cities are planned for the fall following the seminar’s Houston debut.

Editor’s note: to those who find it to be somewhat promotional to feature these two events, let us state unequivocally that we fully acknowledge that it is promotional. While HCTR is not associated with Partners or MadAppeals.com in any way, nor do we receive remuneration from either of them, it is this newsletter’s strong editorial position that these two topics are critically important.

Linking patient data with nearby hospitals and physicians will mean life or death to home care agencies within the next few years. Just as threatening is the rapid expansion of Medicare fraud abatement efforts from a few Linking patient data with nearby hospitals and physicians will mean life or death to home care agencies within the next few years. Just as threatening is the rapid expansion of Medicare fraud abatement efforts from a few target cities to all areas. Honest agencies will be caught up in the sweep if they are not prepared to differentiate themselves from the criminals.

Eliminating fraud requires a completely different effort from the one needed to battle waste. In the case of fraud, a criminal posing as a home care provider may stretch the truth regarding a patient’s diagnosis, ability to function and need for certain services. These folks are not beyond outright lies. In certain parts of the country, people have been caught making cash payments to Medicare beneficiaries in exchange for the use of their Medicare number. They follow this with claims for services that were never provided, to patients who are not sick. The proper response to this problem is to find these people, close their operations and throw them in jail.

In the case of waste, the cure is civil rather than criminal. Here you have honest home care providers serving patients in need of care but not properly documenting the care they provide or not clearly delineating the medical necessity for providing it. To the eye of the RHHI, and eventually the Administrative Law Judge, these payments must be denied but the perpetrators are not criminal. They are simply overworked, improperly trained or lazy.

The proper response to this problem is to educate agency management. Home health agency owners who allow such a situation to exist unchecked need to be convinced to either provide an ongoing staff training program or to ease off on their productivity requirements so that clinicians have adequate time to document properly. Payment denials should be a good way to get their attention.

The buck stops at the owner’s desk
CMS, the Center for Medicare and Medicaid Services, has no mechanism for dealing with waste differently than they deal with fraud. Fines and punishment are the only arrows in their quiver. Solving the problem by helping clinicians learn better documentation skills is the responsibility of the owner of the agency, not the payer. Yes, CMS does provide some training services. It is still up to management to make sure those courses reach the staff.

Judging by the increasing number of Medicare payments denied because of lack of medical necessity — which in practice actually means “lack of documented medical necessity” —  training has not been a priority for too many home health agencies. In fact, the problem of inadequate documentation is rampant in home care. Comprehensive training for home care nurses and therapists is far below the level needed, in spite of the fact that live and online opportunities abound.

Are there consequences? Absolutely. As Medicare’s need to cut costs grows more urgent, good clinicians offering good care with inadequate documentation are just as plum a target for auditors and investigators as full-fledged criminals. And their employers’ fates will be the same, regardless of criminal intent. Agencies unwilling to invest in ongoing, comprehensive training will see their revenue stream decrease by an amount that will dwarf what they would have spent on a comprehensive training program.

Consultants have ethical limits
Recently, we came across a shocking example of what can happen when agency owners make no effort to improve clinician skills. A consultant who has asked for anonymity, for himself and his client, shared with us a letter he wrote, explaining to a regular client why he could no longer represent them before their RHHI and the subsequent appeal levels, QICS, MACs and ALJs.

This agency had been hit with an unusual number of payment denials recently but dediced that the reason was its location within a region CMS has targeted as a high-fraud area. In spite of repeated warnings, the consultant found himself unable to make the client understand why he was able to win back payments in some cases but not in others. “Sometimes,” he told RAC Assistance, “the ALJ is right. The only evidence I can present is the clinical documentation I have been provided. When it truly is inadequate, no amount of legal argument, no matter how skilled or eloquent, can convince a judge to overturn a denial.”

With permission, and with both consultant and client identities masked, we reprint this letter in our next article: “Consultant Fires Client Over Inadequate Documentation.” Following that, under a separate headline, we also reprint some specific examples of the kind of documentation problems the consultant presented to his former client, along with his suggestions of how this client’s staff might have documented differently.

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.”

PHYSICAL THERAPY
I typically work on appeals from various regions. The following is a compilation of what I have found in 38 different physical therapy charts. Compare them to what you are doing and please realize they are all being denied all the way to the ALJ level just like yours are.

Two agencies have on their evaluation forms checkboxes indicating many of the following maladies:

• Antalgic gait a limp adopted so as to avoid pain on weight-bearing structures, characterized by a very short stance phase.
• Ataxic gait an unsteady, uncoordinated walk, employing a wide base and the feet thrown out.
• Festinating gait a gait in which the patient involuntarily moves with short, accelerating steps, often on tiptoe, as in parkinsonism.
• Helicopod gait a gait in which the feet describe half circles, as in some conversion disorders.
• Hip extensor gait a gait in which the heel strike is followed by throwing forward of the hip and throwing backward of the trunk and pelvis.
• Myopathic gait exaggerated alternation of lateral trunk movements with an exaggerated elevation of the hip.
• Quadriceps gait a gait in which at each step on the affected leg the knee hyper extends and the trunk lurches forward.
• Spastic gait a gait in which the legs are held together and move in a stiff manner, the toes seeming to drag and catch.
• Steppage gait the gait in foot drop in which the advancing leg is lifted high so that the toes can clear the ground.
• Stuttering gait one characterized by hesitancy that resembles stuttering.

Your agency frequently creates notes such as the ones I received for one patient:

• “Was in hospital for bronchitis, had decline in function.”
  • Which functions? How can one tell?
• Living situation “capable”
• Pain: = 0
  • Why are we in this home?
• Prior Level of function: “Independent”
  • How does “independent” differ from “capable?”
• Posture: “Kyphotic”
  • To what extent? And how is it adversely affecting the patient?  This is never again mentioned in any note. Where did the posture issue go?
• Full weight bearing, with standby assistance.
• Quality/Deviations/Postures: “Decreased endurance with ambulation”

This is the logical place for any of the aforementioned abnormalities to be recorded. Detail on these brief notes would go far when it comes time to defend a denial of payment for this patient. Poor endurance with walking is the primary driver for the care to be delivered but I know that from talking with this therapist. I could not know it from these notes.

SKILLED NURSING
This example leaves a judge not only with a suspicion that this nurse was practicing documentation cloning but also that the patient’s welfare was placed in jeopardy due to the nurse’s lack of response .

Skilled nursing visit dated January 18, 2009 9:00 AM
the skilled nurse focused on the new diabetes regimen with the change doses three times a day with the insulin, and assess compliance and effectiveness of the antibody therapy that was completed on January 17 to assure that no side effects or adverse reactions occurred. Blood sugar of 180 MG/DL, which is approximately 80 points higher than the normal range. It is to be expected that the patient’s blood sugar will come down with the new medication regimen but an infection and the stress of being in the hospital can elevate blood sugars and is a very common side effect of the patient’s illness.

Skilled nursing visit January 20, 2009
demonstrates the blood sugar is now 216 MG/DL, which is 116 points above normal, and the patient is hypertensive at 184/94. Before leaving the house, the patient’s blood pressure was reported as being 150/80.

Skilled nursing visit January 22, 2009 at 10:15 AM
blood sugar continues to climb at 289, which is 189 points above normal. Blood pressure is 170/80 in the right arm left arm records 165/80.

Skilled nursing visit January 27, 2009 8:00 AM
the patient is still experiencing difficulty with blood sugar levels as level as noted to be 305MG/DL

Skilled nursing visit January 30, 2009 10:30 AM
the patient continues to have challenges with the diabetic regimen, blood pressure 159/76 as noted in the right arm and left arm 155/80. Skilled nurse continues to check the patients for signs or symptoms of hyperglycemia yet the patient states that she is feeling fine, the caregiver verbalize that she is comply with blood sugar checking in insulin management has ordered. The skilled nursing instructed the caregiver on the purposes and action of humulan insulin and reinforced the need to monitor the diet and the blood sugar to achieve optimal results with the new medical regimen.

Skilled nursing visit February 3, 2009 9:30 AM; the nurse notes the blood pressure to be elevated at 165/99; when queried the patient denies symptoms of hypertension, the nurse reported the findings to the case manager and M.D. The M.D. decided not to deliver any new orders.

Skilled nursing visit dated February9, 2009 12:00 PM; patient’s blood pressure continues be 156/578 on the right arm 155 are in the left arm with a blood sugar of 280 mg/dl.

Skilled nursing visit dated March 1, 2009 1:15 PM; blood sugar of 264 milligrams/DL.

Analysis: This nurse admits in this six-week narrative that she waited until February 3 to alert the physician of a patient who had been spiraling out of control since January 18. My conclusion not enough was done for this patient. This type of documentation is rampant in your agency’s notes but is not being managed by case managers or the QA staff. As owners, you must ask why not.

It is this type of documentation that leaves you wide open for a continuous series of post payment reviews. Medical necessity is not clearly defined; patient’s conditions are not being responded to; yet bills for services continue to be submitted. Every agency that allows this to go on has a limited life expectancy. I fear yours is nearing its end unless ownership attends to these patterns.

The hassle of post-9/11 flying is only one reason conference attendance has been down across all industries for nearly nine years. Cost-conscious executives may consider the advantages of networking with peers an important reason to put up with travel themselves but they look hard for alternatives to sending staff. At the same time, webinars and other online training systems have advanced to the point where some of the reasons to go can be simulated online.

Compare the cost of today’s online learning systems with the sum of conference admission fees, airfare, lodging, parking, ground transportation and meals per person and the decision is easy. In home care, no one sends their entire staff to national or state association conferences. Less obvious but also clear is that no one sends more than one or two staff members even to local live educational events.

One reason is simple to understand. Clinicians cannot put their patients on hold while they take two or more days to sit in a hotel auditorium, no matter how excellent the instructor. The other reason might be more subtle. Many people, including executives, believe that one person can attend a lecture, take notes, return and disseminate the exact same content to the rest of the staff.

All theories of adult learning disagree with that belief.

In the case of spoken lessons, a lecturer must repeat a fact six times before he or she can assume two-thirds of the audience has heard it. Calculate the success rate of the delegated workshop attendee who hears information one time and tries to relay it to co-workers a few days later.

Marcia L. Conner, writing in “The Ageless Learner,” asserted, “In today’s business environment, finding better ways to learn will propel organizations forward. Strong minds fuel strong organizations. We must capitalize on our natural styles and then build systems to satisfy needs. Only through an individual learning process can we re-create our environments and ourselves.”

Conference lectures cannot be designed to accommodate individual learning styles. Even books, CDs that can be played in cars and DVDs with video-recorded lectures only address one learning style each. For this reason, many home care executives are turning to the Internet.

Online training systems have a number of advantages, not the least of which is their 24/7 availability. Gathering clinicians together at the same time is a near-impossible task. They also eliminate

Not All eLearning Systems Created Equal

A number of “elearning” systems have surfaced in the last decade. The ones that have experienced the most success offer choices of learning formats for the same material. Those that have limited themselves to one format or another tend to be struggling and may not survive.

• Static text on screen. Some adult learners do well reading book-length material on a computer display, others do not. Many prefer to just have the book in their hands. However, paper cannot be updated with new information as needed. These systems may be offered for online access or distributed on CD, though CDs have the same update restriction that books do.
• Voice-accompanied text. Some systems read the text to you while you are reading it on the screen. Others have a voice reading different text, with the screen text supplementing but not matching the spoken words. This covers two adult learning styles at once.
• Alternating lessons and exercises. With or without voice, some text-on-screen systems offer brief instructions followed by hands-on practice examples. Most experts insist that this is a critical component in successful adult learning.
• Streaming video. Some online educational services have locked themselves into the “talking head” format, where a live lecture atmosphere is recreated online, sometimes with accompanying Powerpoint slides, sometimes without. This is an effective learning method that works for some adults.

Note that each company that elects to serve one adult learning style and eschew the rest rarely reaches its forecasted potential in terms of number of students and gross revenue. In fact, some of them are currently suffering financially from this chosen path and have seen their long-term survival put into jeopardy because of their choice. Customers tell each of them, “Some of my staff likes your format and some do not.” Clearly, learners’ stated preferences are influenced by each individual’s distinct learning style needs.

Though this is not a comprehensive list, here are some of the online learning systems offering home health care and hospice content today.

Silverchair

This privately-owned company, founded in 2002, falls in the category of text-on-screen but with some interesting options. A voice
track, reading word-for-word from the displayed content, can be turned on or off by the learner. Another switch allows the student to see and hear the lesson in Spanish or English. More languages are in the works.

Courses are offered for clinical staff in home care, hospice, long term care and assisted living facilities, with many titles pertinent across these categories. Examples include infection control, blood-borne pathogens, HIPAA compliance, safe-lifting guidelines, HHABN, wound care and others for a total of 127 course titles.

An online, hosted system, management has granular control over course assignments and reports. Certificates of completion are awarded after a student passes each course’s post-test. Silverchair is approved by the American Nurses Credentialing Center and, for administrator content, the National Association of Boards.

Pricing is determined based on an organization’s size. Over 50 employees, the cost is $53 per employee per year. Smaller customers pay a flat $2,500 per year. Users also gain access to an “author and manage content” tool, which designated system administrators use to create their own courses. Since the Silverchair system is primarily text-based, it works on all Internet connections, including dial-up.

The Corridor Group

A pure text-on-screen system, Corridor Home Care & Hospice eLearning Exchange (CHEX) comes from one of home care’s preeminent consulting firms. It offers course content and a comprehensive and easy-to-use learning management system that provides management reports and granular control over the student experience.

CHEX has courses for administrators, professional clinicians, para-professionals and support staff. For those whose learning style needs match, this screen-reading system can be quite effective. As in all online programs, courses are available 24/7. CHEX courses cover safety, organization performance, social responsibility, clinical development and leadership skills.

Unlike Silverchair, CHEX
content is entirely home care and hospice specific, the areas of expertise The Corridor Group has honed since 1989. CE credits are provided and are accepted in 50 states. Outside the CHEX catalog, the system can host customer-produced content, including recorded video streams. A typical CHEX subscription runs approximately $22,000.

The Home Care Information Network

Founded in 2005, HCIN selected a video system for its preferred learning style. Learners comfortable with this format will benefit from the systems ability to simulate the experience of sitting at a conference lecture. Those who learn better reading than listening may want to consider one of the previous alternatives.

Students login to their account in HCIN’s proprietary learning management system and see the list of courses their supervisors have purchased and selected for them. Any PC or Mac with a high-speed broadband connection can access streaming video courses 24/7. Most streaming presentations are accompanied by Powerpoint slides. The recording system is capable of producing voice-only over Powerpoint though that option is rarely used.

Customers purchase courses separately or in pre-packaged collections. Each course or collection is priced
differently, depending on its length and the renown of its instructor. Prices are often custom-quoted based on customer staff size and course popularity, leading to an assortment of pricing for the same material that compares to the range of prices various passengers pay for the same airline seat.

Online streaming rich media touches a number of different learning styles, accommodating more individual needs than text alone or voice alone or even text and voice combined.
Learners will appreciate the ability to view from home at any time and to pause presentations and come back to them later. HCIN suffers most significantly from the lack of an online e-commerce system. Customers have to print an order form, fill it out and fax it to a central office, where someone manually enters the order into a spreadsheet.

The Hospice Education Network

HEN is a venture of Weatherbee Resources. Owner Heather Wilson, Ph.D., a longtime and well-respected hospice consultant, uses the same technology as HCIN and rents space on that company’s equipment to host and distribute its streaming video courses. Most of what has been said about HCIN technology is therefore also true of HEN, including its lack of a credit card payment system, but the comparison ends at the camera lens. Wilson told HCTR that the online payment problem will be corrected soon.

HEN’s far broader course list puts it in the lead as the most comprehensive educational offering for hospices.
Among HEN’s 140 hospice-specific courses for all levels of hospice staff are subjects as diverse as
Workplace Safety, Sexual Harassment, Nutrition at End-of-Life and Grief and Loss. There is also an entire course section devoted to volunteer training. CE’s are awarded to nurses, social workers and counselors. HEN courses are taught by a variety of nationally-known instructors with years of hospice experience.

HEN has a partnership with the End of Life Nursing Education Consortium (ELNEC), providing eight of their core curriculum and, recently recorded for a spring release, nine programs from their pediatric palliative care curriculum. Plans have been confirmed to add ELNEC’s geriatric curriculum to the list, which will appeal to skilled nursing facility staff as well as to hospices. According to Heather Wilson, whose doctorate is in Pastoral Psychology, HEN has just agreed to partner again with ELNEC to provide an end-of-life care curriculum for all VA hospitals.

Course prices are set low for smaller organizations and increase based on a hospice’s average daily census. One course, for example, begins at $60 for one year of unlimited us by the entire staff but rises to $300 for hospices with more than 500 patients. Additional volume discounts are available for multiple title purchases.

MED-PASS, Inc.

The paper forms company dipped its toe in the training ocean by contracting with nationally recognized coding expert, attorney and nurse Lisa Selman-Holman, JD, BSN, RN, HSD-D, COS-C. The company offers Selman-Holman’s expertise in coding and other topics in much the same way HEN does, by contracting with HCIN to use its video recording technology and the same learning management system with its fax-based ordering system.

Each module provides online testing and CE credits. Pricing is determined by organization size, calculated by number of offices or branches and number of clinicians per site in this case rather than by patient census. A single-office home care agency will pay $895 per year for unlimited use of the Selman-Holman OASIS course. Large organizations, e.g. 7-10 locations, will pay as much as $699 per office for a 12-month subscription.

Carosh Media & Marketing

There is one newcomer to the pack. Carosh Media & Marketing, an HCTR affiliated company, throws its hat into the ring next month with an OASIS-C course taught by RBC Limited’s Patricia W. Tulloch, RN, BSN, MSN, HCS-D.

According to Carosh president Roger Shindell, the startup has based its philosophy and technology around current theories of adult learning styles. Most courses will be offered in a variety of formats, including text, Powerpoint, voice and video. Students will be able to gravitate toward the learning style that suits them best and management will be able to purchase many courses in different formats to accommodate differing adult learning preferences.

As a startup, the Carosh lineup is in its infancy but will soon feature home care and hospice clinical content as well as basic instruction for home health aides. “We decided to break out of the gate with OASIS-C because there is such a need,” said Shindell. “Our hope is that the home care community will find it both affordable and an effective learning method.”

Carosh will incorporate an industry-standard learning management system capable of providing management reporting and customized course lists for similar groups of staff. It will be linked to an online ordering system that will accept credit card and PayPal payments. The new company also plans to offer its learning production and management system to organizations, from vendors to multi-site agencies, that wish to use it to produce their own educational programs to reduce wear and tear on their own training staff.

Summary

Online learning systems are all improvements over the waste of allocating substantial portions of agency training budgets to planes, trains and automobiles…and hotel rooms. Which brand an agency chooses will be determined by a number of factors, not the least of which is effectiveness of the learning style offered. The wise manager will include staff in online demonstrations, letting them experience each candidate’s look and feel and weigh in on the final decision.

Price may be less of a differentiator, since the range from lowest to highest is not wide. Surprisingly, simple text-on-screen is priced approximately the same as streaming video, which one would think is more costly to produce. Some organizations will find the availability of CE credits important where others will be less concerned.

Lastly, this reporter must acknowledge HCTR’s longtime bias in this regard. Simply stated, training is infinitely consequential. As important as the choice of a specific online learning system partner might be, it pales in importance against the choice to provide training at all. Historically, home care as a whole has seen staff training as an expense with little return, a budget item easily cut with no consequences when cash flow is strained. Nothing could be farther from the truth. Nothing can be more wasteful, not to mention potentially fatal to the business, than deploying an inadequately trained clinical and office staff.

Editor’s note: for one example of how inadequate training can cost far more than the amounts saved by skimping on a training budget, see our sister publication “RAC Assistance” at http://www.homehealthnews.org.

After studying descriptions of the patient assessment and care plan, try to determine why payment for this episode was denied by the RHHI and why both QIC and ALJ agreed.

Patient Background

• One HHPPS episode provided, 59 days, to 72-year old female.
• Diagnoses: osteoarthritis of lower let, difficulty walking, diabetes type II uncontrolled, hypertension, esophageal reflux and hypothyroidism.
• History of falls without injury
• Functional limitations: endurance, ambulation, shortness of breath on moderate exertion, poor vision.
• Patient oriented, forgetful, anxious.
• Referral made by primary care physician due to exacerbation of osteoarthritis and increase in knee pain. Physician prescribed Celebrex and ibuprofen.
• Son/daughter available to assist with all activities of daily living, monitor blood glucose level.

Care Background

• SN for observation, assessment and education on new medication regimen.
• Physical therapy evaluation determined patient needed assistance to walk at home. She could walk 25-30 feet with a cane and stand-by assistance and displayed an unsteady gait.
• PT provided therapeutic exercise, transfer therapy, gait training, balance training, ultrasound and muscle re-education.
• SN provided education on disease process and assessment for medication compliance and response.
• Patient missed or canceled last three scheduled weekly SN visit appointments and was discharged, one week after the final cancellation, with goals met.
• At discharge, blood pressure and blood glucose levels were stable.

The ALJ Decision

• Celebrex and ibuprofen do not constitute a change in the patient’s treatment regimen requiring SN services.
• Skilled nurse provided nothing more than observation of a chronic condition.
• Patient, with daughter’s help, was able to monitor her own blood glucose levels.
• Three successive canceled visits indicates SN was little needed.
• “The record does not support the medical reasonableness and necessity of the SN services provided.”
• “The record does not indicate a functional decline requiring the skills of a PT.”
• “Physical therapist checked a box at each intervention but provided no description of the specific interventions provided. Thus, it is unknown if the skills of a therapist were required.”

As can be seen, the ALJ made no determination as to whether the patient had shown some improvement over the course of the episode. No judgment was made that the provider did not provide necessary services. Neither the skills of the nurse nor the therapist were called into question. The judge does not even specifically state that the care itself was not reasonable and necessary.

This judge referenced the condition of participation known as G-tag 161. “Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration.” To quote from the judge’s final conclusion, with emphasis added, “The record does not establish the medical reasonableness and necessity of the services provided…”

In this case, it is the lack of comprehensive, compelling documentation that is the primary driver for payment denial. To clinicians who say, “I may not write it down well but I provide excellent care,” ALJ’s are beginning to say, “if you expect to be paid for your excellent care, you had better learn to write it down well.”

Chambers will leave the EHR battle, with its $19.5 billion prize from the American Recovery and Reinvestment Act, to the crowded field dominated by the likes of IBM, Intel, GE, Allscripts, Cerner, McKesson and many others and turn Cisco’s attention to video-based communication systems.

“Imagine if you could access the best doctors in the world from your home or [could have] the ability to interface with your [aging] parents and see how they are doing,” he told TheStreet at last week’s Consumer Electronics Show in Las Vegas. “What the administration is trying to do with its spending is to kick start things – the real growth will come through both the private and the public sector over the next five years.”

As we have reported after the last two HIMSS annual gatherings, Cisco moved into the healthcare segment not only with its array of network routers and other technologies but also with “Connected Health,” a video system for sharing information. The concept is that “telepresence,” a form of high-end video conferencing, is more effective than merely sending X-ray and C.T. scan files across network connections.

Cisco invested a small fortune, not only into television advertising but also by getting its telepresence product prominently placed on Fox’s 24 in the last few seasons. We are not sure if President Obama uses it in Washington DC but “President Taylor” certainly does at Fox Studios in Burbank.

During Chambers’ keynote address at the CES show, Cisco marketing vice president Ken Wirt demonstrated the technology by discussing his diabetes with his doctor, revealing Cisco’s long-range plan to extend the technology to the consumer market. The company discussed plans to eventually offer a home-based telepresence system, which customers will access via their existing HDTV and broadband system, not by purchasing a hospital-grade video system.

Working with Verizon, Cisco will run its first home telepresence trials in the U.S. this spring, TheStreet reports. Other signs that Cisco is betting on the future of video were its 2009 $590 million acquisition of Flip camera maker Pure Digital and $3.4 billion acquisition of Norwegian video conferencing specialist Tandberg.

Chambers predicts that the health IT revolution will improve the quality of care and save money by boosting efficiency. “My view is that you could probably cut the cost of the healthcare system by 25% to 30% and dramatically improve the quality of healthcare by using this technology,” he told TheStreet. “Stay tuned — you are going to see a number of announcements from Cisco this year in the healthcare area.”

If Chambers’ efforts cause an explosion in video traffic, TheStreet noted, it will certainly not harm the demand for Cisco’s switches and routers either.