Need advice re: legality issues

caliotter3 · Mar 18, 2011

Sorry can't give you an answer, but wanted to say that I would not want to be dealing with this. I think your employer expects you to do some underhanded things to make the paperwork right. Perhaps you should look for another job if you can not convince people to start doing things according to the rules.

Isabelle49 · Mar 19, 2011

I have been working in a Medicare certified HHA helping them with 'fixing'/QA messy charts and converting non-oasis to Oasis due to the payor requesting usually after the fact (pt. was already discharged and we need the Oasis to be able to bill)
What has been done there in the past and before my time is someone in the office does the Oasis using the non-oasis eval the best that they can and writing a documentation note in the chart that an Oasis was done per request of payor.
First question: Is there any problem with doing this?
Second question:
There have been charts in which care extended through several cert periods in which a recert may have not been done or done a month late. Many of the times, there is an LPN in there and noone ever sent the RN in to do the sup visit and recert the patient. In order to be able to bill for all those visits, there needed to be an Oasis recert. I have been expected at times to put one in but I am under the understanding that you can't do this off a LPN note b/c an RN never went in?
Can anyone tell me the legal issues with this and if this problem has happened- missing a recert- how it can be properly corrected (or not)
Thanks

Any patient who was not assessed by an RN or PT cannot have an OASIS. These assessments are not acceptable based on LPN visits. Sounds like you are working for a company I used to work for! If your manager tries to get you go commit fraud, run! The Medicare Fraud Task Force is not only going for companies, they are also going after nurses and docs. All your company can do is submit notes on the patients who were seen by LPN only and hope they pay. If they don't get paid, lesson learned.

Mijuo · Mar 19, 2011

Any patient who was not assessed by an RN or PT cannot have an OASIS. These assessments are not acceptable based on LPN visits. Sounds like you are working for a company I used to work for! If your manager tries to get you go commit fraud, run! The Medicare Fraud Task Force is not only going for companies, they are also going after nurses and docs. All your company can do is submit notes on the patients who were seen by LPN only and hope they pay. If they don't get paid, lesson learned.

Thanks for your reply..Maybe we worked for the same company! I know a lot of agencies that run like that and it's a poor way to do business.

I totally understand that you can't have an Oasis Recert/Follow Up assessment based on a PTA or LPN note but what about doing a "paper" discharge Oasis on a patient whose last visit was done by a LPN? I know it's not good nursing practice but is it legal?

Usually these are after the fact due to lack of oversight in the case management dept. and the patient has already been discharged in the system.

thanks for your advice, I am planning on sticking to straight chart reviews and will be ready to leave if they give me a hard time about anything further

Kyasi · Mar 19, 2011

Wow! I'm really astounded and can't imagine an agency operating like this. Since you only have 30 days to transmit Oasis after the SOC, reassessment, discharge etc was actually done, I'd be surprised if this didn't trigger an audit. I can't even believe an agency would allow this kind of oversight to happen. I wouldn't want to be associated with them in any way.

Kyasi

KateRN1 · Mar 19, 2011

First, run. RUN RUN RUN. This is fraud.

First question: Converting to OASIS due to payor source is iffy, if their requirement was for a HHRG score for billing, then that should be known upfront. Someone isn't doing their job in intake.

Second question: Recerting a day or two late happens almost everywhere and is somewhat acceptable, but a month? No way in hades. This is fraud. A recert OASIS "created" from an LPN's visit note is absolutely and positively fraudulent practice.

"Paper discharges" or non-visit discharges are perfectly acceptable, but not off the last visit note of an LPN. If the last visit was not done by an RN, PT, OT, or SLP, then you have to mark the discharge OASIS exactly as per the last OASIS assessment, whether SOC or ROFU. You cannot show any improvement or decline in the patient's situation.

If you are not familiar with these rules, I have to politely suggest that you excuse yourself from a QA/QI role until you have the required knowledge base. Go to the CMS website, read everything there. Go to OASIScertificate.org and download the OASIS-C core documents. Read the Medicare Benefit Policy Benefit Manual. And know the Conditions of Participation like the back of your hand, as well as the rules for your state. This is messy business and I have seen nurses in handcuffs for these things.

A reminder: federal whistleblower law provides 10% of monies recouped to the whistleblower in a federal fraud case.

Mijuo · Mar 19, 2011

First, run. RUN RUN RUN. This is fraud.
First question: Converting to OASIS due to payor source is iffy, if their requirement was for a HHRG score for billing, then that should be known upfront. Someone isn't doing their job in intake.
Second question: Recerting a day or two late happens almost everywhere and is somewhat acceptable, but a month? No way in hades. This is fraud. A recert OASIS "created" from an LPN's visit note is absolutely and positively fraudulent practice.
"Paper discharges" or non-visit discharges are perfectly acceptable, but not off the last visit note of an LPN. If the last visit was not done by an RN, PT, OT, or SLP, then you have to mark the discharge OASIS exactly as per the last OASIS assessment, whether SOC or ROFU. You cannot show any improvement or decline in the patient's situation.
If you are not familiar with these rules, I have to politely suggest that you excuse yourself from a QA/QI role until you have the required knowledge base. Go to the CMS website, read everything there. Go to OASIScertificate.org and download the OASIS-C core documents. Read the Medicare Benefit Policy Benefit Manual. And know the Conditions of Participation like the back of your hand, as well as the rules for your state. This is messy business and I have seen nurses in handcuffs for these things.
A reminder: federal whistleblower law provides 10% of monies recouped to the whistleblower in a federal fraud case.

After a few years working in the field and 1 year in case management, I do not declare myself to be experienced for a QAQI position and have just recently been recruited to help out in this area. I have been reading up on the cop's, know the agency's p&p manual and educating myself on the CMS website.

Most of the business they do is private insurance-only about 20%traditional medicare/PFFS/advantage/HMO. The charts that I am referring to are MA/PFFS that required an Oasis per payor and intake screwed up and had the nurse do non-oasis

There has been a lot of turnover in the intake and scheduling dept. that has contributed to the mess they are.

I am aware of keeping no change to the Oasis for the LPN visit- that is what we have been doing but just wanted to check this out to make sure it is ok.

With the whole recert a month late thing, it is a non-oasis chart but of course as a medicare certified agency they are required to follow the rules with all charts. That was the first time I got an attitude when I told them that I cannot fix it due to the fact that there were only lpns and pta's and the PT was a month late on their recert they submitted.

Mijuo · Mar 19, 2011

To add to my last post, I do agree with everyone that I should run and plan on doing that to another agency- and taking my regular patients with me.....

KateRN1 · Mar 22, 2011

Don't take patients with you. That is totally unprofessional and in many states illegal. Rise above the antics of this agency and be a more professional person.