First - my sincere thanks to all of you who took a moment to fill out the questionnaire regarding this newsletter which I sent out in March.  I read every response.  And I certainly appreciated the comments and suggestions.  Overwhelmingly a monthly newsletter was the favorite frequency choice.......well, I've kinda' blown that lately!  We have been busy and I hope you understand that our work with clients takes priority over newsletter preparation.  I will, however, try to be better organized and more timely with the newsletter in the future.  I promise!  And for those of you who expressed interest in writing an article for a future newsletter -- you'll be hearing from me!

 

To continue our discussion on leadership:

 

 "Just because you're not paranoid doesn't mean they're not out to get you." ~Colin Sautar
 

Don't get me wrong. I don't believe in scare tactics - although there are many agencies today who are frightened.  I don't believe that "they" are out to "get" honest operations that focus on compliance, ensure excellent supporting documentation, self audit and respond to deficiencies quickly and completely.

 

 

You can correct mistakes after they occur, but that truly is an exhausting, frustrating no-win activity.  Anticipation of issues to be examined and resolved is an important activity for a healthcare leader.  I do believe that you should not wait until you have denials, an overpayment demand letter or a visit from a Medicare audit contractor to begin to look at your agency's documentation skills.  It is more cost effective and anxiety reducing to review your own documentation and clinical files regularly -- and take action internally to resolve any issues.

 

RAC--ZPIC--MIC--MCFU--OIG--HEAT--DOJ

 

Lots of initials - lots of organizations who exist to make sure that documentation justifies payment, and that billing and coding practices are appropriate.

 

As we work with agencies to help them prepare for the inevitable interaction with these entities, we find ourselves going back repeatedly to the basics of documentation.

 

With that experience in mind our articles this month deal with documentation and corrections to clinical records.   

 

We've enjoyed a fairly warm spring with lots of rain here in the Upper Midwest.  I hope that you are celebrating spring by spending some time outside working on garden preparation or observing the vegetation changes as you take a walk through a forest preserve.  Doesn't the air smell wonderful?

 

If we can provide you with any assistance, please do not hesitate to contact us.

 

Best wishes,  Beth Carpenter

 

"Let us realize that the privilege to work is a gift, that the power to work is a blessing, that the love of work is success"  David O. McKay

By Elizabeth E. Hogue, Esq.

 

The old adage, "If it is not documented, it was not done;" is unfortunately often true. The consequences of failure to document may be severe in terms of allegations of fraud and abuse.  The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services has repeatedly stated that providers carry the burden of proving that care was actually rendered to patients.  If practitioners are unable to prove that they rendered appropriate care because it was not documented, the OIG and other fraud enforcers may conclude that claims submitted by these providers are false claims.