Agency creates a process for airtight documentation, billing
Agency creates a process for airtight documentation, billing
No more errors and delayed orders
It doesn’t much matter if your Medicare billing and documentation mistakes were intentional or the result of shoddy workmanship. The federal government cares only that mistakes were made that could have cost the government some money. Since the federal government continues its crusade to crack down on fraud and abuse in home care agencies, it’s a good idea to once again review your documentation and billing process.
A Kansas home care agency did exactly that after the director discovered that nurses and managers sometimes forgot to log in signed doctor’s orders.
"We had a lot of new nurses. They weren’t really aware of the big reasons we had everything signed and all the paperwork completed, so I looked at how we could become more compliant," says Charlene Berges, BSN, RN, director of Golden Belt Home Health and Hospice of St. Catherine Hospital in Garden City, KS. The agency makes about 1,200 to 1,500 visits per month.
The agency educated its staff and began a lengthy education and training process for supervisors to emphasize that they need to be actively looking at notes and daily activity sheets.
"Then I looked at how to make my clinical coordinators more responsible for the day-to-day documentation," Berges says.
She suggested they have one clinical coordinator monitor all of the nonlicensed staff’s daily activity sheets and notes, and the other coordinator would review the licensed staff’s clinical activity sheets and notes.
After that process began, Berges decided to expand it and have the coordinators review all physician orders and Medicare 485s for accuracy against what was billed.
"We were finding things where maybe a fifth digit for coding was omitted, and this made a billing error," she explains.
Seeking errors
These are the kind of mistakes that can come back to haunt an agency, and so Berges and other managers worked hard to correct those and eliminate any future such errors. Within six months, they had achieved the mistake-proof documentation process they sought. "I feel a whole lot better if Medicare walks in for an audit right now," she says.
Here’s how the agency, using clinical coordinators, developed its fraud-and-abuse-proof process:
• Train clinical coordinators. Previously, the coordinators were handling intake paperwork. They would check with support staff to make sure a visit was made before it was billed. But no one assessed the quality and quantity of those visits, Berges explains.
"When they were just doing intakes, they assigned the admissions and who was going to do it, but they didn’t look at the recertifications and daily paperwork," she adds. "The nurses just sent them in. We had them typed up, and errors were caught after the fact."
Now, coordinators must look for billing errors, documentation omissions, late physician orders, and other items on each chart every day.
"If someone has overtime, they know why," Berges says. "They also make sure any admission we get for home health actually meets the standards the payer source demands, whether there is insurance, Medicare or private pay."
The clinical coordinators manage every documentation detail that relates to direct patient care. When the two coordinators get bogged down, Berges or a branch manager step in to help.
Berges says she and other managers are confident that when patients are discharged there are no longer any errors such as communication notes that aren’t written. "Therefore, I know when we’re billing Medicare it’s for medical necessity, the patient has homebound status, and skilled care is needed."
• Give clinical coordinators some help. When the daily audits began, the clinical coordinators said they were overwhelmed because they were still doing the old audits, and it was difficult trying to catch up on those whole starting something new, Berges says.
"So we asked three or four of our older nurses who had quite a bit of home care experience, to do the post audits and the discharge audits," she adds. "We formed a committee to help with that."
The committee started the audits in February and was finished by May.
While the clinical coordinators monitor records each day, a special audit committee looks at discharge records, usually within 30 days of discharge. Also, the agency’s occupational therapist, physical therapist, and other staff help with the quarterly audits.
"By the time we do quarterly audits and discharge audits, there’s hardly anything that hasn’t been corrected," Berges says.
• Educate staff and change responsibilities. The agency made sure everyone knew what would be expected of them with regard to documentation.
"I’ve really held their feet to the fire and it’s been kind of tedious," Berges admits. "But now when there’s a documentation problem, you can bring in a team for problem solving because employees feel like they know so much and they feel like they’re in on the planning process."
Employees must know how important it is that every action they take is documented, because otherwise Medicare could say they shouldn’t be reimbursed for what they did.
"Documentation is the receipt for the care we give, and you get the payment from that receipt," Berges says.
• Improve communication between nurses and clinical coordinators. Nurses talk with clinical coordinators on a regular basis. Since the audit process has been made more efficient and focused, the coordinators actually have more time to spend with the staff.
So when a coordinator finds a problem with an employee’s documentation, the coordinator can address it quickly and show the employee how to improve. Previously, nurses wouldn’t hear about a mistake until sometimes several months after they had filled out that patient’s paperwork.
"You have to talk to the person about it while it’s fresh in their minds," Berges explains. "If you wait two to three months after the patient’s discharged, employees won’t remember the case."
Since part of the clinical coordinators’ jobs is to do employee evaluations, they will sit down with nurses to write those evaluations together. "I think these evaluations are much better. Nurses are getting evaluated for what they really do, and they’re getting merit raises for what’s really important," Berges says.
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