Is this fraud?

[adlockwood]

I posted on the case management forum, but thought maybe someone here would know. If you know a sub acute rehab will not take a patient on an expensive chemo drug, is it fraud to have the patient fill the script on the way to rehab through a pharmacy, and treat it like a home med? Some of our inpt case managers think it is, but I can't see how it would be, and may be the only alternative if the patient needs placement and is being turned down due to expensive meds.

[Nascar nurse, ASN, RN]

My question is who would you be commiting fraud on. The facility, Medicare, medicaid? Who?

Medicare. They pay us for providing the care. We accept the deal that we will pay for the residents needs, ie: therapy cost, medications, etc & they will reimburse us the determined rate (not a dollar per dollar amount). If the residents provide the medication, but we then accept that set rate of reimbursement we would be getting paid for services we did not provide.

[adlockwood]

Which is exactly why it is impossible to send someone to rehab who needs 6 weeks of Mycofungin at $15,000 - so they sit in a hospital bored to death and killing our LOS, and risking hospital acquired pneumonia. Let's face it - acute care hospitals are not rehab, it seems there are no alternatives for a medicare patient.

[Nascar nurse, ASN, RN]

Which is exactly why it is impossible to send someone to rehab who needs 6 weeks of Mycofungin at $15,000 - so they sit in a hospital bored to death and killing our LOS, and risking hospital acquired pneumonia. Let's face it - acute care hospitals are not rehab, it seems there are no alternatives for a medicare patient.

You are correct! I get a referral, read H&P, see any mention of fungal infection & immediately quit reading that & start scanning med list. If I find Mycofungin, I quit reading and take the whole packet back to admin and tell them to deny as we can't meet their needs. We simply can't afford to take them. If we get $500/day reimbursement for the resident..multiplied by 30 days we have just burned right thru the $15,000 and it only covered ONE medication. We eat the cost of all the other meds, therapy cost, labs/Xrays, general care, etc. It's really kind of sad but ultimately the only way we can provide care is if we stay open for business and that means staying financially stable.

[SuesquatchRN, BSN, RN]

I may have misunderstood the OP's point. I thought she was saying that the facility would not be informed of the medication so the patient would be admitted. To me, that is the sending case manager committing fraud against the receiving institution.