Getting patient verification of visits: Is there a right way to get it done?

Here’s why it may be in your best interest to verify visits

Depending on the state in which you work and a patient’s point-of-care plan, you may not require a patient verification of visit. Some home care professionals see patient verification as time-consuming and one more step in what is already miles of paperwork. Others contend that by not requiring some form of verification by the patient that a home care visit was made, administrators are leaving their agencies open to allegations of fraud.

So who’s right? Well, they both are. In a regulation-filled industry, it’s often difficult to walk the fine line between protecting your agency and overworking your staff. Hospital Home Health spoke with a few home health care professionals on the issue and found that there are as many answers to the question of patient verification as there are questions. If you don’t require patient verification of visits, you’re not alone. Plenty of agencies take the documentation in the computer as verification that a visit was made. Others don’t require verification from their professional staff, but ask their aides to have their activity sheets signed by either the patient or the patient’s family on a regular basis.

Julie Van Vleet, RN, BSN, interim director of St. Agnes Hospital Home Care in Fond du Lac, WI, says signatures are simply one more needless administrative task, and that in the end, it really comes down to the patient’s word against that of the home care professional. "If the clinician has entered the information in the visit note, is that not proof enough that the visit was made?" she asks. "Why must we overdo things? I’m not in favor of adding one more thing for the clinicians to have signed and bring back to the office. They have enough already. The patients can say they never signed the note, and that it’s not their signature. Who will [inspectors] believe then?"

In the argument against signatures, there is another point to be made. Does the patient actually understand what he or she is signing? As Mark Baff, vice president of sales at Sandata Inc. in Port Washington, NY, notes, this is especially true with senior citizens. As an example, he tells of his grandfather, who received home care and "was so happy that someone was there he didn’t even look at what he was signing. In these cases, signatures by clients don’t really mean a lot."

In spite of her opposition to the signatures, Van Vleet explains that as of Jan. 1, 2001, Wisconsin requires patient signatures on patient visit notes. To avoid confusing paraprofessionals with when to get a signature, she says her agency now requires all home health aide notes to be signed. However, she still views the entire signature verification issue as "a no-win situation, so why keep adding fuel to the fire?"

Lorraine Waters, CHCE, director for Southern Home Care in Jeffersonville, IN, agrees up to a point. "I think it is almost obscene for a professional to have to prove he or she made a visit."

Their word over yours

For a time, Waters’ agency didn’t ask that patients sign a verification form. "[Then] several years ago, we had a request from our field investigator to produce evidence that the employee actually made the home visit [that was] billed. Having a surveyor investigate a complaint that staff never made any visits, as a confused patient stated, will soon change your opinion. "Do you think your investigator will believe you or the patient?" she asks. " Since then, and with a careful nod to fraud issues, we always have the patient confirm every visit. It’s part of our corporate compliance plan.

"This is the new reality. You must be prepared to show evidence that you didn’t commit fraud, and remember, you are guilty until proven innocent. Sometimes we just have to make the best of the hand we are dealt," she says. Waters also points out that signatures can help unveil instances of fraud where "staff actually did not make the visits that were billed."

As simple as it sounds, getting a signature on the right document isn’t always easy. At Arkansas (Paragould) Methodist Hospital Home Health, patient verification signatures are required. Dinah Greer, RN, BSN, director of home health for the agency, says the agency has always had patients sign a nurse’s note, but when it switched to a point-of-care system, procedures changed too. The agency still needed signatures, but this time on a form that was printed out after the visit was made.

"We racked our brains trying to figure out a way to get our patient’s signature on a note that was printed out later in the office," she says. "The only thing that we could come up with, and it seems to be working fine, is to print address labels out that have a place for the patients to sign and place for the date of the visit to be filled in with a statement that a skilled nursing visit or physical therapy visit was made on that day. When the clinicians review and sign their note, they stick the label on the note."

Certainly, back office systems can affect how you document a patient’s visit, and therefore, how you obtain verification. At Lodi (CA) Memorial Hospital Home Health Agency, Rose Mary Radotic, BSN, PHN, director, found that charting was not proof enough that a patient had received care. Lodi Health now utilizes a fill-in-the-dot system that is then scanned into the computer. The questions and descriptions are written clearly on the visit sheet, which the patient can see and the answer. "[Patients] review the completed form and also can have a copy if they request," she says. "There is also space for written documentation to cover exceptions, the chart-to-the-care plan, and a plan for future visits."

"I have been preparing the nurses for the eventuality that when our hospital purchases a new fully integrated system, we will undoubtedly return to laptops [which her nurses disliked], says Radotic. "For now, our system is not without flaws, but it is so simplistic, everyone loves it, and we have less paper than we did with the previous system."

Verification without a pen

For every reason to go with a signature there are reasons not to. And accordingly, there are reasons to go the extra mile. Telephony is becoming increasing popular in the home health care industry. (See "Telephony: What can it do for your agency," in this issue.) The primary hindrance to widespread use is lack of acceptance by state Medicaid systems, many of which still rely on computer systems that are not compatible with today’s technology and won’t accept telephonically submitted reports. Not surprisingly, proponents of telephonic services, such as Baff —whose company makes and markets Santrax, a fully automated time, attendance, and data collection system for off-site locations — is leading the charge to gain national acceptance of what he says is a win-win situation for everyone.

"Right now, the burden is really on Medicaid to allow the use of electronic records in reporting. The stumbling block is that the regulations were written 20 years ago, and we didn’t have computers then. No one ever imagined it would be like it is today. For the world of 20 years ago, they were perfectly good regulations, but the business environment has galloped past the old regs," Baff says. "It’s my belief that for the benefit of everyone, Medicaid should allow the use of electronic reporting — the benefits are clear to everybody," he says. "Several states already have agreed to accept telephony, and we believe we are about to have some success in Texas."

Electronic advantages

There are distinct advantages to going electronic, Baff says. "These systems collect the actual arrival and departure time from workers from the actual visit sight. They record the tasks they accomplish and other traditional data elements, particularly in terms of paraprofessionals. Any data that are necessary for billing and payroll services, including mileage travel, if an agency reimburses for mileage, are recorded."

Telephonic systems, he says, can be customized to interface with an agency’s payroll system so that "with a click of the mouse, the billing export files go to the billing system and then to payroll. It’s all streamlined. No more hassles collecting paper or doing manual data entry and dealing with the errors and delays that occur. You’re getting precise and accurate information into the system and with a permanent, comprehensive audit trail," he says.

The audit trail is perhaps one of the strongest arguments in favor or using telephony, says Thomas P. Gordon, JD, senior account executive with Sandata. "I tend to look at this way. An electronic verification of the visit using telephony, which can timestamp the location and phone number, definitely protects the agency from allegations of fraud and abuse," he says. "In an audit situation, there is nothing better than having this information in an electronic format where you can search and query your visits by client or supervisor or worker. It’s much harder and more time-consuming to gather the same information with paper," Gordon explains.

Meri Shaffer, RN, program manager for HomeAdvantage in Fairfax, VA, says using "a telephony system to track your staff in and out of patients’ homes will give you a caller ID, which to me is primary proof that the clinician was there and for how long. "I know that we like to think our colleagues are honest professional health care workers, and most of them are, but unfortunately during my 20 years in home health, I have seen several professionals commit fraud and have had to investigate my share of questionable visits," she says. "I agree that we are mired in paperwork; that is why I am a strong proponent of automation, but I also cannot condone fraud. . . . It makes us all look bad," Shaffer adds.

HomeAdvantage markets a telephony system and specializes in software development, computer telephony integration, Internet/intranet development, and project management with a special focus on health care, hospitality, and telecommunications.

Lawbreakers usually find a way

Gordon acknowledges that if "someone is interested in breaking the law, then a way always can be found to do so." To dissuade those who are less than honest, he recommends that agencies taking the telephony route, "stick with automatic number identification [ANI]-based systems and technology rather than caller ID-based systems, as caller ID can be blocked." ANI, he explains, "is the same technology the telephone companies use to switch calls between the different carriers and is unblockable."

Elisa Hinken, a nurse consultant and president and CEO of MedMal Nursing Consultant Services (a division of MedMal Consultants Inc.) in Lawrence, NY, says, "Telephony works great if the patient isn’t participating with the worker in committing fraud. Some patients put in their workers’ ID numbers into the phone service and then split the pay so both parties benefit from it. I have seen this with paraprofessional agencies that have cases in excess of 400."

Still she agrees that telephony has cut down on certain types of fraud and that at least on a paraprofessional level, supervision is minimal. "Telephony is not 100%," adds Baff, "but if someone wants to collude, then the truth is [he or she] could find ways about it. This is not big brother, but all in all, it’s better than the traditional way of doing things."

[For more information, contact:

Mark Baff, Vice President, Sales, Sandata Inc., 26 Harbor Park Drive, Port Washington, NY 11050. Telephone: (516) 484-4400.

Thomas P. Gordon, JD, Senior Account Executive, Sandata Inc., 26 Harbor Park Drive, Port Washington, NY 11050. Telephone: (516) 484-4400.

Dinah Greer, RN, BSN, Director of Home Health, Arkansas Methodist Hospital Home Health, 900 W. Kingshighway, Paragould, AR 72450. Telephone: (870) 239-7101.

Elisa B. Hinken, Nurse Consultant, President and CEO, MedMal Nursing Consultant Services, P.O. Box 302, Lawrence, NY 11559. E-mail: medmalnursing@msn.com.

Rose Mary Radotic, BSN, PHN, Director, Lodi Memorial Hospital Home Health Agency, P.O. Box 3004, Lodi, CA 95241. Telephone (209) 333-3131.

Meri Shaffer, RN, Program Manager, HomeAdvantage, 10875 Main St., Suite 212, Fairfax, VA, 22030. Telephone: (703) 352-1830, ext. 8213.

Julie Van Vleet, RN BSN, Interim Director, St. Agnes Hospital Home Care, 239 Trowbridge Drive, Fond du Lac, WI 54935. Telephone: (920) 923-7950.

Lorraine Waters, BSN, MA, CHCE, Director, Southern Home Care, 1806 E. 10th St., Jeffersonville, IN 47130. Telephone: (812) 283-2602.]