Documentation altering/tampering...Is this the norm???

  1. 0
    Hello all...I've been reading a lot of posts recently but havn't seen a topic that addresses my concerns so thought I would start my own.

    I'm an RN in HH about 14 months after 17 yrs in a hospital med-surg floor. My agency uses RNs to do only the Admits, Recerts and Resumps and LVNs do the daily/weekly visits. I received very minimal orientation (2 days in the office reading manuals and then followed a nurse on 2 admits) but feel pretty confident now although I learn something new almost daily. We use Kinsser software for charting via our computers at home.

    My concern is with my Oasis assessments coming back to me for my signature but upon review of them I have noticed many changes that weren't made by me.

    Sometimes it's a Diagnosis (ex: Benign HTN changed to Malignant HTN - I was told that anyone with 2 or more BP meds gets diagnosis of Malignant).
    A lot of times it's Sensory (ex: anyone that wears glasses has Low Vision and can't see medication labels).
    Also frequently changed is the Braden Scale for skin breakdown risk (ex: most everyone winds up being at risk for skin breakdown somehow).
    A biggie is Elimination (ex: urinary incontinence gets checked on everyone! I was told that everyone over 50 has at least stress incontinence and if they deny it, it is only because they are ashamed).
    Another is Neuro (ex: Frequently the box is unchecked for Oriented to Time if I have checked that they are forgetful. I was told that you can't be oriented x 3 if you are forgetful!)
    Nutrition (ex: Every pt is made to be of at least moderate nutrition risk).
    And of course ADLs (ex: every category is typically changed to a higher level/need for assistance.)

    All of the above (and more) is being changed by people in the office that did not visit the patient, are not nurses, and without consulting me and they expect me to just sign it with the changes. When I raised questions about this practice I was told that I had a bad attitude and bad reputation for not wanting my documentation changed. The administrator pulled me aside recently and told me that he is auditing my Oasis especially because after these changes are made, the company is making an additional $500.

    I was under the impression that my job was to complete an accurate and thorough assessment - not worry about how much money each box I am checking is adding or deducting. Having come from a hospital setting where a nurses charting of her assessment is pretty much sacred and can't be changed or altered by anyone, this just doesn't feel right to me.

    So my question is....Is this normal and just an accepted part of the Home Health world?
    Any opinions/advice are greatly appreciated!
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  3. 15 Comments so far...

  4. 2
    This is something you need to live with or leave

    I was also in a very similiar position in my first job

    I worked in a dermatology clinic where it was quite common for people to come in to have a mole checked out.
    Most times it was blatently benign and diagnosed as such, but the doctors would tell the patient that they will remove it anyways. A lot of the time, the patient would wholeheartedly agree because of cosmetic reasons. (it was on the face or other prominebt body part and ugly).

    Since one of the RN's roles was to scribe doctor's charting, after such a removal (and pathology expenses) billing dept would chase me down.

    "you need to change the charting so that there is a medical reason the mole was removed"

    "Just put down it itched, it bled, it hurt ect ect...."


    I upright told billing department that the patient adamantly denied all those symptoms and were merely concerned about skin cancer and that I refused to falsify charting and falsely bill the insurance/medicare companies.

    So they changed my charting for me.

    And I found a new job.

    In fact, not being such a brand new nurse....I'm becoming more concerned exponentially even as I type this.

    Such a sad state of affairs we find ourselves in today....
    lindarn and Not_A_Hat_Person like this.
  5. 2
    I had been approached by a previous employer in HH to change my documentation because an episode had been denied payment by CMS. It was an unplanned discharge (was supposed to be a routine supervisory visit) due to the patient no longer being homebound. (Franky, they probably never were to begin with but I didn't admit them so I can't say). I got "talked to" for discharging them and causing a LUPA, and was also asked to change, "Patient reports she has been driving and is able to leave home without difficulty." I refused. Which, to me, never having seen the patient before was covering my own butt as for why I was discharging them. I am glad I charted it because I would not have remembered accurately the situation if I hadn't, and if it came into question later (which it did) I would not have remembered why I discharged them. Know what I mean?

    Anyway, I also worked for a different agency who insisted that I not lock my OASIS until billing had a chance to review it. I also refused to do this, and it became a sticking point so I quit that job too. Leaving my OASIS unlocked in the computer I saw as akin to completing and signing a paper OASIS in pencil, making it impossible to tell if changes were made and by whom. The stupid thing is there was a way for anyone, billers included, to unlock it and make whatever changes they needed to make and lock it again, and leave an electronic trail of this activity. Not so if I didn't lock it in the first place. Also, I did find my OASIS answers changed which proves my point. I tried to report this to CMS as possible fraud activity but the fools at CMS said, "Unless you have actual evidence of fraud, we're not able to investigate." Well, where is the evidence if there is no paper trail/electronic trail of changes made? Pretty fishy stuff.

    For my most recent HH job which I quit. I was asked to fix my charting on 80% of my visits. Now, don't get me wrong, I am not perfect, but I know HH and had been doing it for several years and know exactly what I am doing and what CMS requires. But, they insisted I update and use key words in every single entry. Not fraudulent, because really it is a silly matter of interpretation and I obliged them. But still, it took 10 hours of unpaid time for me to do so.

    As for which ICD-9 codes were appropriate to assign to the case, I don't give a rip what the billers/coders chose. Not my job, not my problem. My documentation shows the diagnoses and if CMS has issues with the codes chosen by billing they can take it up with the coders. In that department I totally understand that certain case mixes get reimbursed a higher rate and if they can swing it based on the assessment info I provide, go for it, it's how the ridiculous system works and you have to play the game to stay in the race. Just don't expect me to care which Dx gets more money!
    SkidogsGirl and lindarn like this.
  6. 2
    Coverage and reimbursement is a frequent topic of discussion amongst administration / management everywhere (from home health to primary care to hospital settings, etc). Unfortunately, like any business whether healthcare or retail store, budget and profit must be considered. I'm not saying it's right that they alter your charting (especially without specificially pointing out the changes that are made), but it does need to be considered in order to ensure the company will be able to continue providing their services in the future. As nurses, it's hard for us to understand because we're not in this for money -- we're in it to take care of people. But from a completely fiscal stand-point, ensuring coverage of services and reimbursement from insurance companies is very important and directly correlates with the longevity and growth of a company.
    Burlshoe114 and RNMom2010 like this.
  7. 0
    I agree that you need to learn to live with this or leave. You will not win this battle.
  8. 1
    but fraud should not be tolerated/demanded.
    colleenk63 likes this.
  9. 4
    If anyone can prove that their OASIS answers are, indeed, being changed--I would definitely contact a Qui Tam lawyer. With regard to changing benign hypertension to malignant hypertension, this is a prime example of "upcoding" to increase HHRG scores--which increase reimbursements. Medicare views upcoding and making patients look worse than what they are as fraud. Qui Tam lawyers listen to what potential "whistleblowers" have to say and, based upon the evidence, decide whether or not enough evidence of fraud exists. The employee, whether still working there or not, then files a Qui Tam complaint with the Department of Justice. The Department of Justice then is forced to look at the matter, investigate the matter, and make a monetary judgement against the company--if warranted. If there is a fine imposed for fraudulent practices, the employee can receive 10% to 30% of any recovered monies.

    I made the mistake of calling the 800 Medicare number to report three different agencies that I had the luck of working at. One of those agencies received a $60 million fine in Sept of 2011; that agency and another agency I worked for--and called about--are involved in the House & Senate Finance Committee investigations that were just forwarded to the Dept of Justice. Also, nurses are protected by the federal Whistleblower's Act. I contacted a Qui Tam lawyer, after the fact, and he told me that had I contacted them first--his firm would have definitely filed a Qui Tam lawsuit on my behalf against the agencies I had worked at.

    I wish I knew then what I know now. Just something to think about.
    colleenk63, kaliRN, Bella'sMyBaby, and 1 other like this.
  10. 3
    This is clearly Medicare/Insurance Fraud. If you sign an OASIS that has been altered, you are also liable if the fraud is uncovered. RN's who tolerate this activity need to think about what benefits might NOT be available to them in their elderly years, because if the fraud continues there will be NO benefits.

    FYI you can access the Medicare website and report fraud anonymously. Be an ethical patient advocate and nurse, report it!

    If you are too afraid to do so, pm me the information and I'll gladly do it for you.
    Mainframe1, kaliRN, and Bella'sMyBaby like this.
  11. 1
    Last edit by harlee on Jan 25, '12 : Reason: Correct spacing.
    morte likes this.
  12. 0
    Quote from sweetsugar
    If anyone can prove that their OASIS answers are, indeed, being changed--I would definitely contact a Qui Tam lawyer. With regard to changing benign hypertension to malignant hypertension, this is a prime example of "upcoding" to increase HHRG scores--which increase reimbursements. Medicare views upcoding and making patients look worse than what they are as fraud. Qui Tam lawyers listen to what potential "whistleblowers" have to say and, based upon the evidence, decide whether or not enough evidence of fraud exists. The employee, whether still working there or not, then files a Qui Tam complaint with the Department of Justice. The Department of Justice then is forced to look at the matter, investigate the matter, and make a monetary judgement against the company--if warranted. If there is a fine imposed for fraudulent practices, the employee can receive 10% to 30% of any recovered monies.

    I made the mistake of calling the 800 Medicare number to report three different agencies that I had the luck of working at. One of those agencies received a $60 million fine in Sept of 2011; that agency and another agency I worked for--and called about--are involved in the House & Senate Finance Committee investigations that were just forwarded to the Dept of Justice. Also, nurses are protected by the federal Whistleblower's Act. I contacted a Qui Tam lawyer, after the fact, and he told me that had I contacted them first--his firm would have definitely filed a Qui Tam lawsuit on my behalf against the agencies I had worked at.

    I wish I knew then what I know now. Just something to think about.
    What do you mean by " I made the mistake of calling the 800 Medicare number". Are you saying it's too late to file a lawsuit on your behalf now? That would be unfortunate, but I admire the fact you stood up for what's right.


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