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That Whole Fraud Thing, Again


Normally, I do not write much about actual fraud cases because knowing about them does not affect the way good nurses care for patients.  I honestly cannot imagine anyone who chooses to  be blatantly fraudulent would have an interest in reading my website but who knows?  Anyway, I have been following a case in Florida that you might want to keep in mind if you are ever involved with an agency that is not completely above board.

On Jan. 5, three people were sentenced in Miami related to 17M dollars in fraudulent claims being sent to Medicare for home health care nursing and therapy services for patients who were not eligible.  This is part of an ongoing legal drama involving multiple patient recruiters, an administrator and a physician being charged or pleading guilty of fraud.  Here are the three.

Lisandra Alonso was the office manager of ABC home health.  In her thirties now, she will be forty when she gets out of jail but then life won’t be so sweet because she will have to somehow come up with 15.3M.

Jose Ros will only go to prison for 12 months but at age 72, that could be a life sentence.  I hear prison life ages you.  (While I do not approve of patient recruitment, I must admit there is a certain elegance to adding septuagenarians to your marketing team.  Kind of wish I had thought of that.)

Farah Perez,40 is the one who really got my attention.  Farah is a nurse; just like me and just like most of you.

Now that got my attention.  An office manager, a senior citizen and a nurse going to jail.  Sadly, Farah is not the first nurse that I have heard of going to jail in recent weeks.  It used to be that mostly owners and CEO’s were convicted.  Now the rank and files of health care are filling up the prisons.

These three were involved in a scheme where an agency altered clinical records to make people appear to be eligible.  In fact, there were records that showed that the patients had impaired vision when they did not or were unable to walk without assistance when they were.  In other words, it appears as though they exaggerated the OASIS data in order to increase revenue.

Here’s the kicker.  Lisandra, the office manager,  was the one who taught the owners and the nurses how to run a fraudulent agency.  She emphasized the importance of kickbacks and bribes and taught the nurses how to falsify records.

Nurses, beware.  A good office manager is worth their weight in gold.  Many have been in homecare long enough to spot certain omissions in clinical records and they are your best friend when it comes to scheduling and payroll.   They are perfectly welcome to suggest changes when they see something off kilter.  BUT, you do not learn how to take care of patients or document from an office manager.

Anyone who tells you that old people always have pain and impaired vision, is probably right.  Look at the OASIS questions.  That is not what they ask.  You do not apply any blanket answers to questions on the OASIS assessment past the tracking sheet.  You assess the patient, you consider the responses, you look them up if you are unsure and then YOU choose the best response.

If you are not satisfied with someone’s advice on how to answer a question, that’s okay.  Ask for a reference.  I know I do and when nurses ask me to reference something I teach, I am impressed.  Those nurses ‘get it’.  It doesn’t matter how much they trust me, it is their name on the documentation and unless and until I can prove that I am 100 percent mistake free, I am happy to oblige.

Please don’t let this scare you.  Nobody goes to jail for isolated mistakes.  On the other hand, it is your responsibility to know the rules and regs pertaining to your position.  You cannot claim ignorance if a reasonable person in your position should have known what you did not.   For an added layer of protection, call our office to assist you in setting up an effective compliance plan for your agency.  But please don’t call unless you are deadly serious about compliance.  We do not need clients who aren’t.

Until I achieve the status of 100 percent mistake free, your questions are welcome by posting below or you may email.  I’m hoping to achieve mistake free status by June but it might take longer.

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