Jump to content

Probable Fraud. What do I do?

Posted
by NYARN NYARN (New) New

Im going to try to keep this short. I am a manager at a home care company. I had a patient who passed away, however his nurse submitted a visit note for 2 days after he passed. I spoke with her, she has since given me 3 different stories about what happened, the most recent being that she saw the patient earlier in the week and forgot to change the date. I don't believe her. My bosses do believe her and want to do nothing about it. We are due for our DPH audit literally any minute now and I am nervous about doing the wrong thing. What would you do?

Out of curiosity, 1) are you this person's supervisor or what is your role relationship to hers? 2) what were the two other stories?

3 minutes ago, JKL33 said:

Out of curiosity, 1) are you this person's supervisor or what is your role relationship to hers? 2) what were the two other stories?

Yes I am her direct super visor. And the first story was that the patient is forgetful and the second that she must have see them before they passed away but she didn't remember because she has been to busy.

Darn, I have one more question. Is this a matter of her knowing that she did indeed visit him but getting the date wrong?

Or are you saying more that she has submitted a visit note for X date, apparently not knowing that the patient was deceased on that date.

Makes a big difference...

Sorry for all the Qs...

2 minutes ago, JKL33 said:

Darn, I have one more question. Is this a matter of her knowing that she did indeed visit him but getting the date wrong?

Or are you saying more that she has submitted a visit note for X date, apparently not knowing that the patient was deceased on that date.

Makes a big difference...

Sorry for all the Qs...

Thats OK. No she had no idea he had passed until I told her....after she told me she saw him but he probably forgot she was there. It was after I told her he passed that she decided she must have seen him on a different day and forgotten to ask me to change the date.

Edited by NYARN

Ugh. Shoot.

Well, there is a slight possibility still that all those things are true. She visited him sometime in close proximity to his death, he is confused, and she doesn't remember the exact date.

Her practice (with regard to this) is not great, regardless. But she may not be a liar/attempting to defraud. Or, perhaps better to say, this falls short of proving that she is.

I could see it being feasible that she does know she visited him and forgot to document accordingly. Personally I would not have the confidence at this juncture to claim with certainty that this fraudulent. If you don't believe somebody, the correct action (in my humble opinion) is not to discipline without proof, but to verify your suspicion. I don't know how you would do that except to call the family and try to ascertain information about when she was there last. Not great.

Just me, and I have never been in your exact position, I would inform her verbally that this does not meet your company's documentation expectations and must not happen again...and then kind of file this away in close mental reach--in other words, keep an eye out for other irregularities and take action as soon as you have hard proof that there is a problem.

I'll be interested to hear what others say.

17 minutes ago, JKL33 said:

Ugh. Shoot.

Well, there is a slight possibility still that all those things are true. She visited him sometime in close proximity to his death, he is confused, and she doesn't remember the exact date.

Her practice (with regard to this) is not great, regardless. But she may not be a liar/attempting to defraud. Or, perhaps better to say, this falls short of proving that she is.

I could see it being feasible that she does know she visited him and forgot to document accordingly. Personally I would not have the confidence at this juncture to claim with certainty that this fraudulent. If you don't believe somebody, the correct action (in my humble opinion) is not to discipline without proof, but to verify your suspicion. I don't know how you would do that except to call the family and try to ascertain information about when she was there last. Not great.

Just me, and I have never been in your exact position, I would inform her verbally that this does not meet your company's documentation expectations and must not happen again...and then kind of file this away in close mental reach--in other words, keep an eye out for other irregularities and take action as soon as you have hard proof that there is a problem.

I'll be interested to hear what others say.

I get what your saying but isn't DPH going to wonder why we changed the visit dates? And why would she would visit the patient on an off day? Call me selfish but I don't want to have to stand in front of DPH auditors going "um...well...the nurse said...." I get that we have no proof and no way to prove anything (the patient lived alone, family wouldnt even know if we asked) but....its just so sketchy. Or am I being over the top?

Sour Lemon

Has 9 years experience.

3 minutes ago, NYARN said:

I get what your saying but isn't DPH going to wonder why we changed the visit dates? And why would she would visit the patient on an off day? Call me selfish but I don't want to have to stand in front of DPH auditors going "um...well...the nurse said...." I get that we have no proof and no way to prove anything (the patient lived alone, family wouldnt even know if we asked) but....its just so sketchy. Or am I being over the top?

I understand why you're skeptical, but unless you're going to make an all out accusation, you're probably better off "believing" the nurse at this point. You're not claiming to have been there and witnessed her visit, you're only presenting her own documentation.

I don't see why you would need to explain away anything. If it comes to that, let her speak for herself.

Just now, Sour Lemon said:

I understand why you're skeptical, but unless you're going to make an all out accusation, you're probably better off "believing" the nurse at this point. You're not claiming to have been there and witnessed her visit, you're only presenting her own documentation.

I don't see why you would need to explain away anything. If it comes to that, let her speak for herself.

OK. Thanks for the perspective. I just am super obsessive about doing everything by the book.

amoLucia

Specializes in LTC.

15 minutes ago, NYARN said:

Yes I am her direct super visor. And the first story was that the patient is forgetful and the second that she must have see them before they passed away but she didn't remember because she has been to busy.

(My bolding.)

This sounds just like some phoney-baloney TV script for Law & Order - SVU, like where a child dies but the case manager goes backdating the note per facility orders. Problem was the CM never did visits, only backdated faux visit entries. Oh, TOO BUSY, aren't we all!!!

Could it be REALLY realistic to give the employee the benefit of the doubt? I know you have your doubts. Or has she had hinkey problems/discipline write-ups in the past?

Why has this whole thing blown up now? Family threatening? This is a very recent occurrence so technically, you all are still investigating. Esp if you need to check out any past similar issues.

PP JKL is thinking along my lines. Difficult for you to prove without more substance.

26 minutes ago, JKL33 said:

Just me, and I have never been in your exact position, I would inform her verbally that this does not meet your company's documentation expectations and must not happen again...and then kind of file this away in close mental reach--in other words, keep an eye out for other irregularities and take action as soon as you have hard proof that there is a problem.

I'll be interested to hear what others say.

And inform her that she faces termination for any further serious discrepancies like this one.

Also as her direct super, make sure you have a paper trail going up thru Admin to CYA.

If you now don’t trust this employee, then do what many agencies do as a matter of day to day business, warranted or not, “lose” her contact info. Should she be ballsy enough to inquire, “we have no available work”. Sooner or later she will figure out that you have no available work for HER.

Katie82, RN

Specializes in Med Surg, Tele, PH, CM. Has 39 years experience.

You need to cover your backside for DPH. Who do you report to? I would shoot them a message outlining the "incident", your conversation, her reply/excuses. Ask if they have any suggestions. That covers you and will be up to your supervisor to act on. I would definitely keep an eye on this woman - her story involved to much backpedaling in too many directions. I suspect this may not have been the first time. If DPH finds discrepancy, it will be on you unless you do some documenting.

BTW, I have encountered many similar instances of “discrepancies couched as “mistakes””. Clients responsible for signing time sheets are usually in on the scheme and in each instance except one, the agency turned a blind eye, just like you describe your upper management seems to be doing. Be careful to protect yourself.

On 7/28/2020 at 7:11 PM, caliotter3 said:

If you now don’t trust this employee, then do what many agencies do as a matter of day to day business, warranted or not, “lose” her contact info. Should she be ballsy enough to inquire, “we have no available work”. Sooner or later she will figure out that you have no available work for HER.

sounds too passive-aggressive to me.

2 minutes ago, Dln14 said:

sounds too passive-aggressive to me.

But this is what many agencies do.

Olga

Specializes in General. Has 2 years experience.

Forgot she visited a patient? Had 0 documentation, not even started anything? Sounds like bs.

What system are u using for documentation? What kind of visit is that? Regular reassessment or something else (dressing change, for example)?

I would cancel that visit completely, if it's still possible. Better to lose money for one visit than get into this kind of trouble.

Edited by Olga

2 hours ago, Olga said:

I would cancel that visit completely, if it's still possible. Better to lose money for one visit than get into this kind of trouble.

I know nothing here, but if this is an actual legitimate thing that can be done--do it.

FolksBtrippin, BSN, RN

Specializes in Psychiatry, Pediatrics, Public Health.

I agree that you should back the visit out of the system, and refund the client. If you can't back it out, your agency should still refund the client, by whatever means are available. Document your request to have the client refunded.

One thing you know with certainty is that the visit did not actually occur on the date it was billed. If you bill for a visit that didn't occur, that is fraud. If you make a mistake and correct it, then no fraud has occurred.

You may still have a bad employee. But you will not have fraud if you voluntarily refund the client.

Further investigation is needed to determine what went wrong with the employee. Is your employee claiming she visits people and just not showing up? Or did she really misdocument a date? She really does need to be fired if she doesn't actually go to her documented visits. That's just unacceptable.

I visit people too, and my agency bills for my visits. I would be able to check myself for something like this. I keep a written agenda that lists everyone I need to see for each workday. I can always go back and look at it, and I need to. I am the type of person who will easily forget whether I did that thing Monday or Tuesday. This has saved me a few times-- when my computer failed to save a note for example.

Do a little digging. If she did this to one patient, she probably did it to others.

If she's poorly organized, she needs an action plan.

Either way you need to be watching her more closely.