“We have clinicians complaining that we have them document too much, as if that was a bad thing. Ah, but they are all so happy that they have the documentation when CMS tries to get its money back.”
by Tim Rowan, editor
This front-line analysis by a healthcare at home nurse supervisor summarizes one of the most vexing problems facing the 12,000 plus Medicare certified healthcare at home providers here in the middle of the healthcare reform movement. In response to a shrinking Medicare Trust Fund, the fraud, waste and abuse (FWA) eradication efforts built into the Affordable Care Act, and an exploding elderly population, the Center for Medicare and Medicaid Services has instructed its contractors to put a tourniquet on the fiscal bleeding.
Like literal tourniquets, however, sometimes they save a life at the cost of a limb.
These CMS agents -- Medicare Administrative Contractors, Qualified Independent Contractors, Zone Program Integrity Contractors, and Recovery Audit Contractors -- either receive and pay claims from Medicare and Medicaid participating clinical providers or review those claims for FWA after they have been paid. They have been commissioned to look for indications that a provider might be intentionally defrauding the government payer. They are also empowered to deny or recoup payments from non-criminal operators who inadvertently waste government money by providing medically unnecessary care. (See the pertinent paragraphs from the 2015 fiscal report, elsewhere in this week's issue.)
In addition to these two payment denial reasons, contractors have discovered that CMS will back them up if they deny or recoup payments for care that was, in fact, medically necessary and in all other ways legitimate but was not correctly documented as such. Though CMS will not answer any reporter's question on the subject, speculation abounds that there are quotas imposed on contractors to reach minimum denial percentages, as well as about the existence of per-denial financial rewards, which the contractor may pass along as an incentive to employees.
A recent HHS report revealed the outcome of these incentives. The gross improper payment estimate for FY 2015 is 12.09 percent of claims. In home health, 2015 is projected to see 58.95 percent of payments declared improper, up from 51.38 percent in 2014. The report cites "documentation requirements to support medical necessity of services" as the reason that home health is an extreme outlier.
Nurse's Documentation? Or Doctor's?
"It may be almost 60%, but that is 90% because of Face-to-Face denials!" we were reminded by Denise Shaffer, RN, Sandata's clinical product design specialist.
Ms. Shaffer is a brilliant, common-sense nurse with years of front-line experience as a field nurse and, later, supervisor. She successfully guided Sandata's ICD-10 compliance project, where teaching clinical principals to software developers apparently taught her to make her points with strength and clarity, as she did with us.
"Look, nurses want to provide the best care; they want to produce the best possible documentation," she told us. "But it can be so frustrating when they do everything right and then the MAC says, 'Nope, the doctor didn't say all the right words on the F2F form so the whole episode is denied.' Palmetto took the most advantage of this loophole but they all did it until CMS changed the rule."
She is certain home care's nearly 60% improper payment rate is a temporary anomaly that will revert to a number closer to the gross healthcare average as soon as common sense returns to the F2F document rule.
Making an auditor's nefarious task easier is the direct cause and effect line that can be drawn from decreased payment rates, through owner/administrator pressure to slash costs, and ending on demands administrators place on staff to increase productivity. Urged to complete more visits per week, clinicians have no choice but to take documentation shortcuts, which lead to accusations of fraud, waste and abuse...and payment denials. This chain of events strikes one as a classic Catch-22. CMS initiates the problem, then punishes care providers for reacting in the only way that could have been expected.
Technology's role unclear
Obviously, the tools clinicians use to document assessments, care plans, and visit notes are in a position to mitigate the problem by erecting virtual guardrails to keep clinicians from taking risky shortcuts. Less obvious is whether software should be performing this service, or even whether it is somehow ethically obliged to do so.
To sort out the ethical question, we asked several healthcare at home software company executives and product designers to help us understand software's proper role in helping, or forcing, clinicians to create audit-proof documentation. We were surprised that what we uncovered was an absence of consensus on the question. Hence, what follows better resembles the beginnings of a lengthy, complex conversation than it does an exposition of concrete solutions and guidelines. (As always, readers are invited to join the conversation by writing firstname.lastname@example.org)
Where it began...
Before getting into the opposing viewpoints, though, we begin with a complete description of the problem. The best one came to us from HEALTHCAREfirst CEO Bobby Robertson, who said his company has spent many years and millions of dollars trying to understand and solve this problem. He has come to this conclusion:
"Medicare payment cuts are the main culprit. Home Health payment rates have been reduced almost 10% from 2012-2016. Over the same period, the cost to run a home health agency has gone up substantially. The task of compliance alone is a significant expense to an agency (nurse competency testing, training, quality assurance on documentation, ICD-10, etc.), but nurses are more expensive too. Many hospitals are currently turning away patients, not because they don’t have available beds, but because they don’t have enough nurses. They’ve resorted to paying significant sign-on bonuses, increasing salaries and more, all of which puts an additional burden on home health agencies to attract and keep nurses. This additional cost is not optional, and unfortunately comes at a time when their payments are continually being reduced. Certain approaches we software vendors take can fuel the fire or help to solve the problem, but ultimately it’s all about the nurses.
So, how does an agency deal with this dilemma? They can do like Amedisys is doing, sell their lavish office buildings and cut layers of management, but most typical community based home health agencies (80% of HHAs) did this many years ago. They can reduce their visits per patient to cut costs, but again, most have already done this too. This leaves them no choice but to demand more visits per day from the nurses they do have, and this is what creates the documentation nightmare, which results from nurses not having the time to thoroughly review the care plan, planned interventions, and stated goals, etc. at each visit. Many simply do the visit and deal with what is in front of them at the moment. This is a recipe for insufficient documentation and, ultimately, improper payments that are later taken back."
Several executives agree with Robertson that software can fuel or extinguish the fire. Homecare Homebase COO Tom Maxwell told us that EMR software "goes a long way toward helping or hindering clinicians' ability to capture accurate, consistent, compliant data – what we refer to as their ability to provide 'defensible documentation.' The primary cause of improper payments is lack of documentation to support justification for services or supplies billed and insufficient documentation to determine errors. It includes improper documentation of medical necessity and other errors made by improper coding."
Helping may not be as easy as it sounds, Maxwell added:
"Home health caregivers are given a harder hill to climb because of the volume of data that must be documented, reviewed and approved at each step of a patient’s care to ensure they are being serviced properly, in the right setting, and within the guidelines of what is medically necessary to achieve their end goal. 'Defensible documentation,' simply defined, is a visit note that accurately, consistently and thoroughly documents the status of the patient, their condition, the nature of their service needs and the care plan to support those needs and achieve their ultimate goals. In the process of visiting patients in the home, caregivers collect copious amounts of information and use it to form a care plan that supports the patient's diagnosis and their physician's requirements. Caregivers must also be vigilant to ensure that every visit note is in sync with that care plan and directive. Should a patient's condition change, caregivers must adjust accordingly and seek proper approval."
So what is software's proper role?
Here is where opinions begin to diverge. Maxwell answers this question with a software feature list, explaining, "The software used by the agency absolutely makes a difference in the agency’s ability to properly adhere to these guidelines and produce the correct documentation to satisfy CMS requirements. This necessarily requires the software to be somewhat specific and prescriptive in the type of information it requires from the caregiver and must include proper checks and balances along the way to insure oversight into the care of the patient. (See the article elsewhere in this week's issue for the combined feature list compiled from the generous input we received from Allscripts, Homecare Homebase, HEALTHCAREfirst, Kinnser, and Thornberry.)
"Not so fast," cautioned David Cole, speaking for himself, he made clear, out of his 30 years of experience in home healthcare as both agency owner and technology vendor, not out of his current role as VP of Sales for HHA Exchange. "It is not the software that has a nursing license or that signs its name on 485s and visit notes. It is not the software that writes, 'Caregiver instructed in medication management' or 'Continue with POC' or any other inadequate visit note that fails to show payers that the visit was medically necessary. The nurse, the nurse, the nurse is the licensed clinician responsible for knowing the Home Health Conditions of Participation, for assessing the patient, and for submitting professional-level documentation. Whether the nurse is using software that helps or hinders is irrelevant; he or she is still responsible. At the end of the day, you cannot blame the software if a claim is denied because a visit was actually not medically justifiable, or because sloppy documentation made it look as though it wasn't."
Is there a middle ground?
Kinnser Software founder and CEO Chris Hester falls squarely between Maxwell and Cole. "We listen closely to what our clients tell us they need," he explained. "That way, we stay out of the fray. They tell us they want a patient's schedule to be automatically updated for all caregivers if one nurse on the case submits a transfer OASIS and puts a patient in the hospital, so that no one goes out to the home unnecessarily. But at the same time they say, 'I don't want my software to tell my clinician what to do.'
"And I agree with them. Software cannot determine, 'this patient is fine, discharge him.' It cannot possibly know all the reasons why this patient should or should not be readmitted to another home health episode. Maybe there are still goals to be met. The only way software should help is to predict consequences based on history. For example, it could legitimately say, 'This exact kind of episode has been denied 500 times by a RAC.' and then allow the clinician to decide."
Hester realizes that, regardless of the structure you build into your software around medical necessity, if the agency wants to admit that patient, they are going to find a way to do it. Plus, if you build safeguards into the EMR around documentation accuracy and completeness, he believes, it could potentially inhibit the good actors. "If we built in some kind of 'insurance policy' to stop those who want to operate 3 to 5 deviations from the mean, we would too often inhibit those who are only 1 or 2 deviations off." Hester prefers to provide information that educates, not to handcuff clinicians.
Some say software should be helpful
Marie Finnegan is the Director of Solution Management for Allscripts' Home Care division. Her comments fall squarely on the side of software vendors accepting their responsibility to put up the guardrails that force clinicians to produce audit-proof documentation.
"First and foremost," she asserts, "a software solution should ensure data completeness. When a clinician completes an OASIS or HIS (Hospice Information System), the agency should have confidence that all of the required elements have been documented. The solution should provide reference material or guidance on a question or response, should the clinician need clarification while out in the field. It should help clinicians with documentation consistency. If they chart that a patient is alert and oriented, it should prevent them from documenting that the patient is in a coma.
"Software solutions should also drive the type and timing of documentation required. The solution should alert clinicians to what is due and when, so the clinician doesn't have to remember the rules. The solution should, of course, follow regulatory requirements and, where possible, hide the complexities of the requirements by aligning with the clinicians’ natural workflows as much as possible. For example, if a clinician enters 'wound care' into my EHR, it should automatically produce an order."
Acknowledging that software should also be flexible enough to enable agencies to address their unique programs or initiatives, the Allscripts executive circled back to what many consider to be the core problem. "Lastly, and most importantly, the solution should be easy to use. The most accurate documentation results when charting happens at the point of care. In short, a Home Health or Hospice EHR needs to be easy to use, provide guidance, and enable clinical judgment, so clinicians can focus on caring for their patients."
Without a doubt, clinician errors that stem from pressure to increase productivity is an issue every supervisor, administrator, and agency owner must address. Nevertheless, human memory is the primary cause of inaccuracy. Notes completed in the patient's home are always more complete and more accurate than notes completed at the end of the day or, heaven forbid, at the end of the week. If the software clinicians have been given is not, in Marie Finnegan's words, easy to use, whether it also provides guidance and enables clinical judgment or not, it pushes nurses and therapists to complete their notes after rather than during the visit, which leads directly to payment denials.
More than one way to be helpful
Putting up guardrails that guide a clinician toward best practices may be one way to improve documentation and reduce improper payment accusations but Delta's Bill Bassett insists that Ms. Finnegan's final statement is the best way to go. "Maybe we shouldn't be putting up barriers that force compliance; maybe we should be removing barriers that interfere with a nurse's natural inclination to be compliant," he said in an interview. "At Delta, we don't fuss over laptop vs. iPad or how to get a nurse to document correctly. Nurses will document correctly if you let them. We focus on making our clinical EMR so easy to use that it is more likely that documentation will be completed in the patient's home."
He told us stories of nurses who complained about having no home life, working on patient charts until after midnight every night, who switched software and began to get 80% to 90% of their documentation done in the home. "This is how you increase accuracy," Bassett asserts, "by avoiding the consequences of naturally occurring memory failure caused when charting happens 12 hours after a visit. You don't so much build barriers to prevent errors as you take down barriers that prevent productivity. You can still offer accuracy and compliance reminders and safeguards, but you don't have to build them in such a way that they make documentation a burden."
Compliance vs. popularity
What each of these executives and product managers struggle with is the age-old conflict between what is good and what is popular. Cola outsells juice; sugared corn flakes outsell oatmeal; and less-demanding software outsells software that encourages in-home charting and supports accuracy. To remain in business, software vendors need to make sales, so they have an incentive to give clinicians what they want, which is often less-demanding software that permits behavior that puts the agency at higher risk for payment denials, ADRs, improper payment takebacks, lengthy appeals processes, and crippling financial disorder.
In an example we have used before, if your software sales person demonstrates a feature that makes it easy for clinicians to copy text from one visit verbatim into the next visit, turn and run. Clinicians may love the convenience but ZPIC auditors are trained to look for this exact red flag. When they find it, they assume you are doing many other things wrong and they select your agency as their next pet project.
The healthcare at home agency owner has a hard decision to make when considering a new EMR: invite the ire of nurses or of auditors, risk losing clinicians or risk lowering defenses just as Medicare contractors are revitalizing their offenses for a renewed attack. Just as the software vendor has an incentive to be popular, so does the agency owner.
Black, white, or gray?
The opinion David Cole presented, which, it must be stated, is not his alone but widespread, is correct. In the end, the nurse puts her license on the line with every document she signs, no matter what tools her employer puts in her hands. At the same time, Bobby Robertson's analysis cannot be ignored. The employer who wants to put a strict software tool at the nurse's disposal is the same employer who wants her to complete 30 visits in a week. The employer who wants to cut costs by selecting low-end software is the same employer who expects nurses not to invite the attention of auditors.
It gets worse, so much worse that we have to tell this final chapter without naming names.
We have also been made aware that one popular software vendor, with a product that is known to be extremely lax in supporting documentation compliance, has made a corporate decision to win market share at all costs. In the course of one of our interviews, we were asked this rhetorical question, "How do you compete with this? A home health administrator tells me, 'I like your product much better than these other guys, but they offered me a three-year contract with an opt-out after 12 months and the first 12 months are free!' I told him he was inviting ADR problems but he said, 'How can I turn down free?'" This interviewee's answer? "Ask your sales person to give you the names of ten or twenty customers who exercised their option to cancel after the first twelve months. They will tell you how you turn down free."
There has to be an answer somewhere in the middle. We will keep looking for it.
©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. email@example.com