runrn

I am not sure if what you describe falls into the category of fraud, but I wouldn't hesitate to say abuse at the very least. In either case, if medicare starts to review these cases you will start seeing all that money do a backwards flow. And if that flow is too substantial to recover from, then the whole ship sinks. Doesn't seem worth the risk does it? Not to the average semi-educated individual, but to folks who don't truly understand the rules and risks thereof, more money is simply just that: more money. Amusing thing about that is when a nurse stands up to improper services given to patients or improper billing, the owners or managers of these agencies get fired up and make you feel like YOU are stealing from THEM. How dare you try to wrongly take away our income? Then they remind you of all the patients that have to be cared for and all of the employees that would be out of a job. I wonder if medicare ever feels like this? Except only thing is, their responsibility is to millions of people, not only those currently on medicare, but to their children and grandchildren, etc. also. I would say their stakes are somewhat higher.

Powernurse: First of all you are right in saying you shouldn't sign off on visits you are not sure were done. I may be off in my practice but: If I knew the particular nurse well, was sure of her abilities, the patients for which these visits were done had no issues with this HH agency such as no nurse showing up or poor nursing care. I would be a bit cautious on signing off on any major medication changes especially if you see a problem resulted from this change or some type of confusion surrounding any of the care given. Don't hestitate to read the other notes surrounding the visit in question to establish if there were any problems that you weren't made aware of or don't feel comfortable with. Of course, this goes without saying, make very certain that you were employed at the time the visits in question were made. If all these things are satisfied, I would have no problem signing off on these notes but I would state very clearly that from here on out you wont sign anything longer than what is acceptable as far as overdue paperwork is concerned, unless an unforseeable event occured (it would be an unfair imposition on your time to have to repeatedly do these things, because as you can tell it takes much more time to research the chart in making certain no problems surrounded these visits). Nurses do have to protect themselves from fraudulent activity, but I am afraid sometimes we are so fearful that we sometimes fail to act reasonably concerning some issues. Check the rules with your board of nursing and also with medicare and state guidelines, if you find nothing on this issue as far as if any rules will be broken in signing these documents, then you may want to consider the advice I've given. It is always a good call to think before you act, so you did good!!

For some reason, nursing seems to be one of the worst fields as far as supervisors not adhering to federal laws concerning employment. Most seem to have no clue when they are breaking laws and putting the company they work for at risk for lawsuits, fines, etc. One would think that a place of employment would educate the people who represent their names better than that. I wonder if they are with the thought pattern that these nurses went to college so they should at least have minimum knowledge of employment rules. Not so. It would take all of a couple of hours to read through the rules/laws to get a basic understanding but there are very few who take the initiative.

It beats the heck out of me that nurses would risk their entire career by encouraging fraud within the medicare system. And for what? Most of these nurses are on a typical salary with no special perks. How is it that they take that kind of risk at a time when whistle-blower lawsuits are at an all time high? I think there should be mandatory education on fraud before a nurse enters the home health arena with major point being: If you get convicted of medicare fraud, even if you don't lose your license, you get excluded from the entire program itself. Which means you can't get a job working anywhere that medicare is a payor source. Correct me if I'm wrong here.

I used to work for an agency that had "team conferences" that consisted of asking every person involved with patients care to give their opinion on the oasis questions. It was a joke...most times the answers were never the same and it would end with the supervisor choosing the answer that would yield the most points on oasis score. When the time came for the R.N. to do the recert, the results of the team conference were given to you as though it were your guiding light. If your answers didn't jive with the ones given to you, then you would get hell. I certainly have nothing against getting input from nursing assistants who know these patients the best, but as far as oasis questions go, I only resort to doing this if I feel the patient isn't being forthcoming, or if I felt I didn't get my point over well enough to get an accurate answer, and if I'm teeter-tottering over two choices. But it has to be my choice, I have to know the assistant well and trust her opinion. I once read somewhere (maybe on here) that the oasis is not a "group effort". I liked it so much I used it one day at work when they irritated me to the point of wanting to hurl my chair at them. They didn't like it, but it beats the heck out of an armrest upside the head. (Kidding, really)

Unfortunately, there are some agencies out there that are unable to make it financially without "cheating". What gets me is that they won't invest the money that it costs to properly train nurses to code correctly. Lots of dollars are thrown away because of improper coding or the sequence of the coding. It's cheap, ignorant, and illegal to try to "recoup" money in the scoring section of the oasis questions. I recommend when you fill out your oasis responses to carefully and fairly check them, giving credit where credit is due, but above all, they should be the truthfully answered according to your assessment. Check over for errors and then write the answer in bold letters smack dab in the middle of the area alloted for that question and circle it. Anytime that you must make corrections (for errors only) you should briefly explain and then write out correct number. In other words write "error made my correct response is #2" then sign your name. Don't just initial. This makes it tough as hell for anyone to game the system using your documentation (they can still change answers but it will be obvious these changes weren't initiated by you). That way if there is ever an investigation into the agency, there will be no doubt which answers were legitimately "changed" by you or not. Folks that check these things pick up rather quickly on your patterns of documentation as this is one of their many tools of fraud detection. Make it simple for them. I never thought I would see the day that nurses not only have to protect themselves with defensive charting, but really need a certified copy and a witness to that documentation. Remember, when it comes down to it, the very ones who asked you to fraudulently change your answers will throw it all back on you. Don't expect an honorable act from a dishonorable person. I think it is important to know that it is perfectly fine for office staff to question your oasis responses in cases where you indicate a HH aide 3 times a week but yet indicate the patient functions independently and safely. The first response should not be "you need to score them higher" it needs to be "please check for accuracy and congruency". It may be possible they dont need the hh aide service or not as frequently. Any time you start hearing things such as "we need 2 more points to get them to level blah blah", you are witnessing fraud within the medicare system which just so happens to be a federally funded program. Parole has been abolished in the federal prison system.

You are getting the shaft. No way around it. Continue to say "NO" when you are bogged down. If they get upset with you, don't even acknowledge it. They know better and you should not have to explain such simple things to them.

I like the part about nasty little dogs. I'm thinking more like "nasty little nurse managers that forget what it's like to work in the field". They can't help you with any of your piles of paperwork or anything else because they barely have time for lunch. So far I have YET to see them miss ONE lunch break OR be late for one. Also yet to see one take less than one full hour.

First of all, you are not going to change anything there. And by the sound of things, there is a lot to change. What you can change is your involvement with it by changing employers. Believe it or not, there are agencies in this business that do things the correct way yet are still able to be profitable and keep folks employed. The truth is, they may never get caught. The flip side of that is: in this day and age it has become common place for employees to file qui tam or "whistleblower" law suits. I'm sure most are familiar with these terms. It basically means when someone (usually an employee of the offending agency) has actual knowledge (that can be proven) that an agency or employees of an agency are committing fraudulent acts within the medicare (or government payor) system, they file a lawsuit against the agency. If able to prove the agency was indeed fraudulent then the employee who brought this behavior to the light is able to receive payment up to 1/3 of the amount of fraudulent payments given to the defendants. So if an agency made 300,000 dollars from their fraudulent billing, then the employee would receive up to 100,000 dollars. Not too shabby for a rable rouser.

I do believe that every RN working in home health should educate herself on the oasis questions and how to properly assess for and answer them. Medicare has several educational sources on this subject that are excellent for the home health RN. The answers should be well thought out and checked over for accuracy. She shouldn't answer these questions with just reimbursement in mind, but by the same token, it should not be totally disregarded either. All home health agencies should provide mandatory education on the Oasis and they should make it as fun and interesting as possible. But as you know, from my previous posts, nurses (or anyone for that matter but MOSTLY nurses) changing an RN's documentation (and this IS documentation don't forget that) makes the hair stand up on the back of my neck. These people should be asked: "would you take a patient chart and pull out regular visit nurses notes and start arbitrarily changing what these nurses documented to the point that it no longer resembles what she initially charted?". Most will look at you as though you had just asked them to rob a bank. Why? because changing a nurse's documentation is falsification in documentation in the worst sense. It's bad enough when you falsify your OWN documentation....and it can lead to severe punishment by state boards of nursing for an R.N. or LPN. Imagine what the treatment and punishment would be for a nurse who changed ANOTHER nurse's documentation would be? That would be the hot seat not to be in. I would think that if a nurse took the bold (and not so smart) step of changing a nurse's documentation, it would be for the desperate cause of absolute must to simply save herself from being hung in the notes...or to simply cover up a mistake she made (hopefully not one that caused any harm to a patient). However, RN's, LPN's and other staff routinely and nonchalantly changing an RN's documentation simply for the financial gain of the agency puzzles me to no end...how does this happen, how does a nurse get to that point? What factors are considered when she makes the decision to risk everything she is worth in order to step up the dollar amount paid to the agency for which she is employed? One of these days, along will come an RN who will discover her documentation is being changed and she will react strongly by notifying her state board of nursing. Thing is, they won't just investigate her complaints, but they will look to see if a pattern of abuse has occured. I think it's safe to say--- that home health agency will sound more like sunday morning at church with all the praying and gathering that will be taking place.

I am wondering: with having to cover 10 counties...how does that work with the 50 mile radius limit that is imposed on most agencies.....in louisiana, our rules say 50 miles because they dont feel you can effectively manage to take care of patients needs if they are more than 50 miles away...not sure what your rules are just curious.

When I read your post I hate to admit this but I was relieved. Relieved because the same thing is happening to me....and has been for a while. I voiced my opinion a while back and I was made to feel like I was a trouble maker. I am per visit and over the next few weeks my amount of scheduled visits dwindled--I suppose in an effort to punish me. Things eventually went back to normal as far as visits. I didnt notice them making any changes without consulting me for the next few months....but today I found several that were changed without so much as asking my opinion. Needless to say this time I'm not going to wimp out on them. I have made copies of everything and read over the medicare guidelines and information regarding fraud. To be quite honest it hacks me off to no end that someone would blatantly alter my assessment of a patient in order to get a higher rate of pay. It disgusts me when a nurse or anyone else that is granted the utmost trust by our medicare program abuses that trust and does it in the name of 'the company'. Not that it matters because it doesn't but these same nurses don't get one penny more for committing these fraudulent acts. They come off sounding as though they have been brainwashed the way they disregard their own felonious ways in support of milking the system. They sound retarded when they say things like "well now we aren't breaking any laws here...I mean the answers are the answers it just depends on how you look at them and who does the judging". I want to say "exactly you wench, when I sign on the dotted line it is my judgement that is represented here and not yours....and by the way oasis is not a group effort".

Rosey--did I read correctly that you are perdiem only. On call is usually given only to full time staff at most places. REASONS: Pay is pathetic for on call. Full time staff get benefits, vacation, insurance, and sometimes shopping at the mall while on the clock. Part time or perdiem get zilch. You dont work you dont get paid. Full time staff takes call at crappy pay as sort of a pennance for getting all the perks. So yes maam you are damn straight that if you dont feel like getting your poor little pregnant self up out of the bed to go to some bullcrap visit to end up getting nothing but a measily 25 or 30 bucks you should not have to. You are right for not wanting to take call---doesn't matter why....whether you are pregnant or have a toe ache you dont owe them this. Do what I did....I told them I was perdiem which means you decide if you want to take the work they give you....and guess what I dont want the on call work. If they insist that you take call and threaten to fire you then you are not actually "per-diem" this would be holding you to the standards of expectations from a full time employee. So then you should ask for some benefits. They cant have their cake and eat it too, but I have seen a many try it.

How do I verify that Oasis answers that I have documented are correctly entered into the system by data entry person? Agency no longer keeps the printout verification sheets with the original oasis that the RN's do. This is curious to me especially since higher ups complaining about RN's not documenting pt's "sick enough". Does anyone know of an out source I can use to verify this stuff. I make copies of my originals in case of future legal questions but does my obligation end there? It wouldn't seem fair to hold us responsible for something we have no way of being able to verify, no way to access the system with no password given to us. I, however, want to know.

If not too much trouble I would like to see them too. The format we use for nurse notes and home health aide assignment sheets are pathetic at best. Thanks runrn