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Posts tagged ‘Home Health Compliance’

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, 34, was sentenced to 78 months in prison and two years of supervised release and was ordered to pay $15.3 million in restitution.
  • Jose Ros, 72, was sentenced to 12 months in prison and three years of supervised release and was ordered to pay $395,000 in restitution.
  • Farah Maria Perez, 40, was sentenced to six months in prison and two years of supervised release and was ordered to pay $118,000 in restitution.

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.

Test Results

We keep receiving results from the Medicare 101 quiz.  What interests me most isn’t the scores that people in general are receiving.  Individual low scores could be the result of any number of things besides knowledge.  What I find interesting, and occasionally  amusing is the number of questions that a whole lot you answered incorrectly.

Understand that green represents correct answers and pink represents wrong answers.  Here is the result for the question that reads:

Teaching and training is a skill only if the subject matter taught would be considered skilled care by a nurse.


And yet, isn’t that what we do every day?  We teach and train on medication administration but giving meds is not a skill.  We teach a patient how to eat a nutritious diet altered specifically for individual disease processes.  The real question to consider is whether or not the teaching is required to improve the patient’s condition.

The problem with teaching is that we never seem know when to stop.

Look at question 34.  The question read:

Your patient was admitted 7 weeks ago after being diagnosed with CHF and continues to refuse to adjust his diet resulting in multiple hospitalizations. He is able to verbalize all the components of a sodium restricted diet. As you knock on the door, you see him through the window eating a hotdog and some french fries. What do you do?


Most of you got it correct but a full 30 percent of you were ready to ditch the patient as soon as you could.  Could it possibly be that compliance with diets and meds might require more than education?  I used to think so but look how my peers answered the next question which read:

Which of the following is a skill?


So let’s get this straight.  The patient knows all about a low sodium diet and yet you find him eating my two of my three favorite foods (chocolate is the third). And 43 percent of you said that teaching the patient a low sodium diet would continue to be a skill.  He knows the diet.  He is not compliant for a reason.  The reason for non-compliance is where your skill needs to be directed if possible.  It could be that the patient wishes to die and wants to prolong the process because it’s a once in a lifetime event.  Or, it could be that he cannot afford the food or is completely dependent on his son who spends most of his father’s money on crack cocaine for food so he is stuck with hotdogs and fries.  Social workers come in handy in these situations.  Revisit post about teaching versus coaching.  Try something new.  Teaching has already been tried and it apparently didn’t solve the patient’s problem.

The overall scores for the Medicare 101 quiz was 75 percent.  There are a couple of questions that I must have written poorly.  78 percent of you think that verbal orders should be cosigned by the physician prior to billing if at all possible.  There’s no ‘if at all possible’ about it.  Orders MUST be signed prior to billing.  When 78 percent of you think otherwise, I either posted this on the Federal Prison blog or the question is just too confusing.  Forgive me.  I wasn’t trying to trick you.

We are planning a two day conference which just so happens to coincide with the LSU/Alabama football game on January 8 and 9th.  The first day will devoted exclusively to the fundamentals of home health including coverage.  If you feel that you or one or more of your nurses should have scored better, consider joining us.

In the Zone

There are new kids in town and they aren’t very nice. Zone Program Integrity Contractors have made their presence known in Home Health in Louisiana. Our friends in TX and Florida have already met these folks. Now it is our turn.

So, what exactly is a ZPIC? The Zone Program Integrity Contractors are under contract with CMS to identify potential fraud and abuse using data from the National Health Claims database among other sources. Utilization patterns, error rates, diagnoses and high cost services are analyzed.

In Louisiana, the ZPIC contract has been awarded to AdvanceMed Corporation. AdvanceMed has also been awarded the contract for about half of the states. SafeGuard Services is the ZPIC contractor for Florida and Health Integrity is the contractor for Texas.

Why is it important that you know this? Because the letter that is sent to clients does not seem to be very important on the surface. Instead of saying, “Welcome to Hell,” on the fax cover sheet, it just goes on to address the administrator with some boring background stuff. You may get a faxed letter prior to receiving the certified one in the mail.

If you get one of these letters, don’t panic but don’t ignore it either. I assure you that neither of these options will produce the results that you want. The letter is the very beginning of a long, long process that will likely last for years. So, stay cool, warm up the copier and keep reading this week’s posts for further information. Meantime, stay on top of your incoming mail and faxes.

If you have any questions or want to share any ZPIC experience with readers, please feel free to leave a comment below. If you actually have a letter and feel like talking, call me. 225.253.4876.

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