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Chart Corrections/Fraud?

Home Health   (1,515 Views | 7 Replies)

MotoRN34 has 1 years experience .

976 Profile Views; 24 Posts

So my HH company wants me to change my answers in my SOCs so that they are reimbursed to the max. My only problem is the answers they want changed are not what I assessed and are completely false. What will happen if I refuse to "correct" them? Will I get into trouble with Medicare or will the company just not get reimbursed?

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13 Followers; 4,056 Posts; 31,531 Profile Views

As best I know (haven't worked in HH but the basic thing you are asking about involves universal principles to some extent):

-You will not get in trouble with CMS over charting that accurately represents your assessments. Your company will not get the reimbursement they seek if they have not provided services at the level they have billed.

-They are asking you to commit fraud. Changing your charting to portray a different situation is not an option.

-They could be accused of fraud for billing for services not provided.

-You could face employment-related consequences such as termination or discipline if you are not completing the assessments (and associated documentation) that are appropriate and necessary for your company to be able to receive full reimbursement for the services they are providing related to the patient's condition/diagnosis. In other words, if you're not doing your job and they are unable to bill because you aren't rendering appropriate care (and documenting it), that is a different matter.

-You could face retaliation if you raise a ruckus about this - - that still doesn't mean you should enter fraudulent documentation. I personally would email my supervisor and ask them to explain what they want me to do. I would save any responses as evidence of what they are asking of me. Then I would tell them I'm unable to do it (not until I have hard proof of their demands, though). **This is not to be taken as any kind of official advice. It is simply how I would likely handle it.**

Officially, I suggest you seek legal advice. And in the meantime, do not acquiesce to any of their requests that you know represent fraud.

Edited by JKL33

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MotoRN34 has 1 years experience.

24 Posts; 976 Profile Views

16 minutes ago, JKL33 said:

As best I know (haven't worked in HH but the basic thing you are asking about involves universal principles to some extent):

-You will not get in trouble with CMS over charting that accurately represents your assessments. Your company will not get the reimbursement they seek if they have not provided services at the level they have billed.

-They are asking you to commit fraud. Changing your charting to portray a different situation is not an option.

-They could be accused of fraud for billing for services not provided.

-You could face employment-related consequences such as termination or discipline if you are not completing the assessments (and associated documentation) that are appropriate and necessary for your company to be able to receive full reimbursement for the services they are providing related to the patient's condition/diagnosis. In other words, if you're not doing your job and they are unable to bill because you aren't rendering appropriate care (and documenting it), that is a different matter.

-You could face retaliation if you raise a ruckus about this - - that still doesn't mean you should enter fraudulent documentation. I personally would email my supervisor and ask them to explain what they want me to do. I would save any responses as evidence of what they are asking of me. Then I would tell them I'm unable to do it (not until I have hard proof of their demands, though). **This is not to be taken as any kind of official advice. It is simply how I would likely handle it.**

Officially, I suggest you seek legal advice. And in the meantime, do not acquiesce to any of their requests that you know represent fraud.

Thank you for your reply. So I am completing the appropriate documentation based off of the information I receive from the patient and my own assessment of the patient. They are wanting me to change my answers to make it appear that the patient is "worse" than they actually are. I do not want to do this and I am contemplating quitting this job. 

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13 Followers; 4,056 Posts; 31,531 Profile Views

4 hours ago, MotoRN34 said:

Thank you for your reply. So I am completing the appropriate documentation based off of the information I receive from the patient and my own assessment of the patient. They are wanting me to change my answers to make it appear that the patient is "worse" than they actually are. I do not want to do this and I am contemplating quitting this job. 

You are wise to be very careful about this and to strongly consider getting out of there.

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MotoRN34 has 1 years experience.

24 Posts; 976 Profile Views

8 hours ago, JKL33 said:

You are wise to be very careful about this and to strongly consider getting out of there.

So I ended up quitting. Now they keep calling me to come back in to "do right by the patients" and make the chart corrections. Unbelievable

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Emergent has 25 years experience.

8 Followers; 2 Articles; 2,931 Posts; 66,900 Profile Views

3 hours ago, MotoRN34 said:

So I ended up quitting. Now they keep calling me to come back in to "do right by the patients" and make the chart corrections. Unbelievable

They sound entirely disreputable. 

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MotoRN34 has 1 years experience.

24 Posts; 976 Profile Views

7 hours ago, Emergent said:

They sound entirely disreputable. 

Yes they are. I'm very happy with my decision. The good news is I already have an interview with an insurance company and I hope all goes well!

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32 Posts; 1,976 Profile Views

Being properly trained in OASIS is key.  In any home health setting, I would suggest taking OASIS training or reading CMS guidelines and see what it is really asking.  Are they asking you to change your charting or change your OASIS....Remember CMS is not asking what they do and how they do it, they are asking if they can perform their task SAFELY.  For example M1860-ambulation...what are you scoring them if they use a walker or nothing at all, but have fell 3 times in a month, or you documented they can only ambulate 10 feet without stopping to rest due to pain, dyspnea, weakness, etc....they would benefit from a wheelchair, but do not have one.  Per CMS the correct OASIS response would be 5-Chairfast, Unable to ambulate and unable to wheel self, Per CMS-the clinician can not assess the ability to use a wheelchair if they don't have a wheelchair in the home....however they would be safer with one....Your goal is to get them therapy to improve them and make them safer or assist them with getting a wheelchair and making them safer in which you then can improve them to a 4.  Their ambulation in M1860 also includes their safety ambulating down the driveway, uneven surfaces, etc...so if you chart any of the mentioned things, then yes you can justify an OASIS change. Then if M1860 is scored a 3 (requires supervision-which all your home health patients should to be SAFER or else they wouldn't be needing home health) or higher, your correct response to M2020 medication management is a 3-Unable to take medications unless administered by another person-Yes, this one gets skeptical from clinicians...however CMS is not asking how they are doing it, they are asking if they are safe...if they require supervision or more with ambulation, then they can't safely ambulate to go to medication, reach cabinet, and take medications. They require another person to complete the activity-SAFELY.  Then throughout your episode, your job is to teach medication management and safety and then you can improve your outcomes at the end. You can take a fairly young Post-Op patient and score them very high on OASIS per CMS guidelines, taking into consideration their pain, obesity, comorbidities, functional limitations post-op.  Pain is also taken into consideration into OASIS questions.  M1800-grooming-this includes washing hair.  Can a person with a fresh rotator cuff repair or even a pacemaker placed that has limited ROM to an upper extremity wash their hair without assistance? With one hand?  This is just a basic crash course in OASIS to maybe help make sense of some of those things.  CMS is all about safety and our goal in home health is to improve in them self managing themselves.

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