Fraudulent visits - yes I brought it up!

[salvadordolly]

I'm a DON at a HHA. I have an LPN who we've caught a few times and has been accused many times of fraudulent visits. She's on probation with the BON for the same thing in the past. Every time I bring it up to my administrator for disciplinary action, she never wants to do anything!! All the people in the office and in the field can't stand her because she's making $150,000/year while they make 50-60 and actually do their visits. My administrator wants proof, but when I give it to her, she says it isn't good enough.

I have started expressing these concerns on her BON quarterly report, but the state simply extended her probation for another year. I even have MD's calling to say that they don't believe the blood sugars she charts. Her patients have really high HG A1C's or she claims they have high blood sugars, gets them on a sliding scale and boosts their visits to tid.

There are several people we know she doesn't see tid. She's very charming and I can't get any of the clients to rat her out. It happened once, but since the patient was psych, it was dismissed. She refers many clients to the agency, which is why I think the administrator doesn't want to get rid of her. She also insists on taking all these patients and has 26 visits/day!! It just isn't possible to do that many. Any ideas on how to "catch" this person? How does your agency handle these types of nurses?

[Not_A_Hat_Person, RN]

A nurse at my agency was caught doing fraudulent visits, complete with fake vital signs and forged signatures. She ended up losing her license.

[n'ville]

You can declare your rights and protection under the "whistle blower act" and report the agency for Medicare Fraud if these visits are paid for by Medicare. I am sure private insurance carriers would also be interested if they are paying for services that are not actually being provided. And like others have said, Medicare Fraud is a federal offense.

[Loodlow]

I supervise 70plus nurses doing private duty for children. I have seen my share of fraud. I report it to the state board of nursing, reverse the charges for the hours billed, and terminate the nurse. Period. That is my responsibility as a RN and as a US citizen. If my administrator bucked me, I would be gone. I refuse to put up with fraud. It is very very hard to prove it, there are lots of sleazy people out there. We have had several parents who have made "deals" with nurses to split the check, and sign their notes. One mother actually showed up at my office, complaining the nurse owed her money. Makes me furious. My license is on the line. It sounds like you have more than enough proof, and your administrator is a disgrace. Report it to Medicare, and the state and run.

[nurseprnRN, BSN, RN]

If your agency issues a laptop or tablet for her on-site documentation, (and you certainly should), entries can be electronically timed AND you can have a GPS chip in it to track where it goes. Consider that. You can also buy free-standing very inexpensive GPS-tracking gadgets to attach to, say, staff name pins, which are then downloadable to show where they've been that day and when. They use them around here to track snow plow contractors to verify their billing. Big Brother-ish? You betcha. How much do you want to avoid being called out for Medicare/Medicaid fraud? Do the risk-benefit analysis and I'd go for the tracking.

[KelRN215, BSN, RN]

I do not see how anyone could possibly believe that this nurse is doing 26 visits in a day. I did six today and it took me the whole day.

[BabaLouRN]

Maybe she had 26 patients visit her at her house!! LOL

[Isabelle49]

It would be in your best interest to document, document, document what is happening. If an audit is done and visits prove to be fraudulent, you could very well be pulled into the middle of this mess and it won't be pretty. We had a nurse fake her visits and when she was caught, our DON didn't want to fire her. I suspect it is because she did not want to let Medicare know about it as the missing visits may have resulted in a much lower pay rate. She was fired and sadly not much longer afterward she died in her sleep.

[Bubbles]

So the question remains what do we do when we know there is Medicare fraud? The situation as described does not seem to even need to be proved given that actually doing that number of visits is not humanly possible! Do we want to keep hospice as a Medicare benefit? Do we want Medicare to survive such insults? I recently read an article on this site about being a 'whistle blower' and the need for the person sounding the alarm to protect themselves by seeking the assistance of a nurse attorney. Just last evening I saw on the news where six employees were fired because they blew the whistle for being required to 'rubber stamp' physicians to the state medical board who did not meet the qualifictions. For not wanting to harm the general public these employees were all fired and now they are on the news. And don't you just want to know the names of the doctors who should not have been licensed in my state?

[MikeFNPC, MSN]

It's not possible to do that many visits in one day, at least not consistently. I'm currently transitioning into an FNP role after over 15 years in home health. Most agencies have some form of sign in process for each visit in addition to a log that's kept in the home. The agency I'm at now pulls the home log at the discharge visit for quality control. Additionally, LVN's where I'm at are required to have ride-along visits once a year. You could ride with her on one of those 26 visit days just to see what she's doing; although I couldn't imagine doing that.

[Libby1987]

Man, am I ever naive. These kind of things are pretty much responsible for the insane amount of documentation the rest of us legit agencies have to comply with.

I've worked with a lot of contract staff who have worked for different agencies and there has been some cross over with another local legit agency, I've never heard anyone share anything remotely close to what has been described here.

And I would have to have starving children before I'd be within 10 miles of such a practice.

Amd TID visits? I haven't seen that since we were paid FFS pre reform, how is that a financial benefit for the company with PPS?