Medicare Fraud?

KSU-SN · Feb 14, 2018

I was told the question is asking not what the pt can do or is currently doing but what is SAFE. It's all about safety

chare · Feb 14, 2018

I was told the question is asking not what the pt can do or is currently doing but what is SAFE. It's all about safety

And who is best qualified to make this decision? The nurse and occupational therapist that evaluated the patient in her home? Or the administrator in the office?

OldDude · Feb 14, 2018

In relation to what you have posted with no other information available...it is fraud.

Libby1987 · Feb 14, 2018

Hi, I am working in HH and I love the actual work, it is the charting that drives me crazy. My supervisors keep changing my OASIS/ assesment answers to ones that just aren't true, especially in functional scores. I am guessing that the aagency gets paid more if the patient is graded as being in worse shape?
For example, a pt with chf, copd, dementia. Still walks talks, continent, bathes self. No walker, cane needed at all. My answers were downgraded to umust use bedside commode, unable to transfer self. Then OT came in and rated her independent all adls, which I would agree with. I am baffled.

That must be some pretty mild dementia if the patient is independent in all ADLS, which would mean another person isn't even needed to be anywhere on premises. And no endurance issues with CHF and COPD? So Caregiver could be at the movies while patient bathes and meal preps?

I'm independent, you're independent (assuming), your co morbid dementia patient is likely not independent but if you're willing to bet your license that you could leave the patient entirely alone without increasing any risk then perhaps they are independent. And then I would ask why are you seeing a patient who is functionally and cognitively so independent?

Sarcasm intended to get point across, not to be a jerk.

OldDude · Feb 14, 2018

That must be some pretty mild dementia if the patient is independent in all ADLS, which would mean another person isn't even needed to be anywhere on premises. And no endurance issues with CHF and COPD? So Caregiver could be at the movies while patient bathes and meal preps?
I'm independent, you're independent (assuming), your co morbid dementia patient is likely not independent but if you're willing to bet your license that you could leave the patient entirely alone without increasing any risk then perhaps they are independent. And then I would ask why are you seeing a patient who is functionally and cognitively so independent?
Sarcasm intended to get point across, not to be a jerk.

I think the point OP is making is that someone falsified her physical assessment.

Libby1987 · Feb 14, 2018

I think the point OP is making is that someone falsified her physical assessment.

My point is OP is implying fraud when there is a clear lack in her and her coworker's understanding of oasis.

caliotter3 · Feb 14, 2018

If there is a problem with how the OP is doing her documentation, then it would be upon the management to bring her into the office for a session on expectations and how to do it to get reimbursement or what view to use to come to a proper conclusion paperwork-wise. In other words, give her the training she seems to need. It might be expedient to blindly revise her work, but it is not helping anyone in the long run. This is said without even addressing the issue of whether there is fraud or not. After this face to face session, it would be up to the OP to decide whether or not she can do things the way they want and whether she wants to remain employed there. I totally disagree with revising her paperwork without getting her involved in the process. That course of action tends to point to the conclusion that there is a reason they don't want the employee to know what they are doing and why. Perhaps it is for the best that she make plans to leave this job.

OldDude · Feb 14, 2018

My point is OP is implying fraud when there is a clear lack in her and her coworker's understanding of oasis.

Not understanding an oasis has nothing to do with outright changing a nurse's documentation from self ambulation to unable to transfer...but I'll defer to caliotter3's post, pull myself back in, and hope for a positive outcome. Thanks for the perspective.

KSU-SN · Feb 14, 2018

If someone other than you is changing your documentation that is wrong...if they are suggesting that you downgrade some of your answers due to what can the patient safely do then that is one thing but if your supervisor is taking it upon him/her self to change Your answers then that is not right. My agency sends us an email once they audit our OASIS and makes suggestions but never changes anything for us

Libby1987 · Feb 15, 2018

It is common and legal practice for the coding department to make recommendations and then the clinician either accepts or declines them. If OP's agency is truly changing her answers without her agreement then OP should leave a company with those illegal practices. OP described her reaction as baffled, that makes me think "changing my answers" may not be literal.

I can't say whether OP's patient needs more than minimal assistance but I can say for certain that clinicians' struggle with accurately understanding OASIS intent and assessment is universal and in my experience even training doesn't always provide clarity as it is counter intuitive to clinicians', nursing in particular, training and previous work experience. Therefore I am hesitant to support claims of fraud by anyone without comprehensive oasis competency.

OP, I would certainly clarify whether they are changing your documentation without consent or making recommendations. I would also question how your OT could conclude that a patient with CHF, COPD and dementia could be 100% independent in all ADLS. That is just as big of a red flag as is it limits care that the patient may require and be eligible for. I know that if a therapist assessed my cognitively impaired co-morbid parent, possibly just out of the hosptial for an exacerbation, and withheld or prevented treatment and services, I would be furious and might consider it reportable.

And to the motivation of the agency, oasis assessment is tied into PPS reimbursement but it also measures the performance outcomes for all patients regardless of payor by comparing 2 points in time, admission/resumption to discharge.

love2banurse89, BSN, RN · Feb 15, 2018

Ask for some training in how the OASIS is coded. When I worked in Home Health and got training I was really surprised at how things were scored--according to Medicare (so definitely NOT fraud). It's been several years but I do think that the score is based on what the patient can do "safely" which can change a lot of your answers.

In defense of the people who changed your scores--I was a Clinical Supervisor for awhile and did the audits and changed some scores; it's surprising how much info you can get from a patient's records and justify the changed score. However I ALWAYS explained why I was changing an answer, so the nurse would understand the rational. And if the nurse argued that her score was accurate I trusted her--she was there in "real life!"

Request the training--it's in their best interests to give it to you so you can score it more accurately AND the person auditing it doesn't have to change the score!