Probable Fraud. What do I do?

[NYARN]

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?

[caliotter3]

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.

[Dln14]

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.

[caliotter3]

2 minutes ago, Dln14 said:

sounds too passive-aggressive to me.

But this is what many agencies do.

[Olga]

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.

[JKL33]

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]

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.

[NRSKarenRN, BSN, RN]

I've encountered this same home health scenario: several times HH visit note submitted by RN dated 2 days post patients death reported by aide. RN response: "Wrote wrong date on note". As caregiver for husband, was contacted by his HHA regarding aide visit pattern after different aide found to have submitted visit notes but patients never seen.

To evaluate concern fraudulent billing:

1. Checked computer for staff scheduled to visit patient on date of death, week prior and looked at notes to see if any notation of RN visit/comparison patient assessment RN/Therapy/Aide documentation on same day.

2. Called patients home to speak with family to confirm day of week patient visited by staff: "Conducting periodic quality audit of our clients -- can you tell me when A, B, C saw your loved one last week /on____ date. Did staff cancel/rearrange visits often? Was care plan followed by staff. Do you have any concerns regarding care provided by our staff? Thanks for allowing agency to care for your family. "

3. Pulled day sheet for date in question to see if other patients listed -called them as above.

4. Patients family able to confirm date visited --no problem. Added non-clinical note " XYZ confirmed RN visit on___date. " 1st time issue with nurse: verbally counseled. Client lived alone, no way to confirm: non-clinical note entered -- "Mistaken date entered on note. Client lived alone, unable to confirm date visited. Notified billing not to bill for service". Changed visit type in computer to Non-billable. Notified business manager, Clinical Mgr/DON + QA staff so no surprise at audit.

5. Family denying visit -- detective hat applied. Day sheets for the entire week pulled. All patients visited on same day called --all denied nursing visit, inquired when nurse last saw client. Confirmed other visit date accurate, end of issue.

6. Most visits confirmed: Written counseling, action plan.

7. Unable to confirm ANY visits performed: Management/HR notified usually termed staff immediately. Unable for rehire RN's entire caseload patients/ family contacted -deny visit. Billing Mgr notified: all unconfirmed visits changed to non-billable; previously billed care adjustment filed to non-billable and monies returned. Care written off.

Better to loose some monies rather than loosing contract/being barred by Medicare/Medicaid + placed on OIG list.

[caliotter3]

NRSKaren, thanks for providing a thorough example of actions that agency management SHOULD be taking in such instances rather than turning a blind eye and thus encouraging the fraud. Would like to add that I have heard of agency managers or insurance investigators "staking out" the address when they suspect fraud, noting no apparent arrival or departure of suspect employee, confirmation with client at time of checking up. When I have to have the "insurance fraud talk" with clients, I always mention that the insurance payors could very well do this.

It is unfortunate that cases where active fraud is being practiced can be staffed with aiding/abetting nurses who may actively "bully" a new nurse to keep their mouth shut. This allows the practice to almost become systemic with some agencies/home health nurses.

[NurseBlaq]

On 7/28/2020 at 7:25 PM, NYARN said:

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.

I don't trust her just from what I read. I would most likely fire her or there would need to be massive proof she was actually there because now I would be worried about did she lie in the past?

[NYARN]

Thanks everyone. The nurse explained that she saw the patient when she was in the area a few days earlier. We decided to believe her but put her on a PIP. She will need to get signatures for visits going forward.

[Been there,done that, ASN, RN]

21 minutes ago, NYARN said:

Thanks everyone. The nurse explained that she saw the patient when she was in the area a few days earlier. We decided to believe her but put her on a PIP. She will need to get signatures for visits going forward.

Everybody knows this nurse lied about this incident. The question is, how many other visits has she documented to get paid, but never stepped into the home?

Good luck with the audit.. somebody is going to catch on.

[Alex Egan, LPN, EMT-B]

As others have said the biggest thing is to not bill the visit. The lost income is a drop in the bucket to what might land if the powers that be decide its suspicious and go digging through your entire agency looking for issues. I assure you they will find them if they look hard enough. The management should take the loss and move on.