Medicare Fraud Archives - Page 2 of 2 - Haydel Consulting Services

Mar 25

Who’s Beverly Cooper?

New Place of Residence for Beverly Cooper

Why should you even care who Beverly Cooper is? A friend, Kelly, sent a link to a recent HEAT team arrests. Because I have worked so much with fraud over the past couple of years, almost nothing surprises me anymore. Here’s the exception.

Beverly Cooper admitted to Federal Authorities that as a registered nurse:

‘she and others conspired to defraud Medicare through home health care companies operating in the Detroit area, including Reliance Home Care LLC, First Choice Home Health Care Services Inc. and Accessible Home Care Inc. According to court documents, Cooper fabricated nursing visit notes and other documents to give Medicare the impression that she had provided home health care services, when, in fact, home health care was not needed and/or was not being provided’.

Wow! We are not talking about a rogue nurse. This woman systematically with cooperation from her employers signed legal documentation for the sole intention of defrauding the government. The total billed fraudulently was over 5M.

This is the stuff that makes headlines and sets examples of what happens to people who commit fraud. It is dramatic and so far away removed from our daily practices that we just look at it in awe.

What we miss is that the worst part about this case isn’t the legal implications at all. It is the clinical documentation that is now part of a patient’s medical history. It is the patients who were not seen. It is those patients who did not meet eligibility requirements and were seen.

So, while it may not take a lawyer to determine that the behavior here was illegal, I wonder if the lawyers and judges understand the gravity of the compromised clinical care. Do they fully understand the the harm that could come to a patient when a hospital or other provider relies upon fiction stated as fact in a clinical record? Do they even understand how easy it would be for a patient to die because medications or allergies weren’t documented appropriately?

There’s one way to ensure that they do. The judge presiding over the case, The Honorable Victoria Robertson, can be contacted at:

United States District Court
for the Eastern District of Michigan
Theodore Levin U.S. Courthouse
231 W. Lafayette Blvd., Room 123
Detroit, MI 48226

Chambers Telephone Number
(313) 234-5230

Let Judge Robertson know, if she does not already, that this case is about so much more than fraud. If we, as nurses, do not speak up, who will? Who better understands the ramifications of fraudulent documentation than a nurse who has tried to take care of a patient who is relying on poor (though not fraudulent) documentation of a prior caregiver?

I hope they allow Ms. Cooper a computer in the Federal Penitentiary so she can spend her money on the internet. I hope the Amazon order is enough to offset any regrets she has about compromising patient care. Most importantly, she should take up a healthy lifestyle because there are many nurses who would not be comfortable taking care of her should she become ill.

Jan 18

3 Comments

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.

May 14

Tell Me a Story

When working with ZPIC clients, it is important to remember that Zone Contractors have been told to address eligibility more so than quality of care. Quality of care issues are to be sent to local licensing agencies and QIO’s if found in excess in a chart. Keeping this in mind, there are only a limited number of factors that make a patient eligible for home health:

They must be under the care of a physician
They must be confined to the home
OASIS data must be accurate and timely
Care must be reasonable and necessary
Must need skilled nursing care on an intermittent basis for reasons other than obtaining blood
Must be a Medicare beneficiary

Mostly the eligibility requirements are easy to prove. If there is no signed order, the patient is not considered to under the care of a physician. If the patient’s clinical record does not consistently reflect homebound status, the patient is not considered to be confined to the home, etc. OASIS data is either transmitted or not. And if your patient isn’t a Medicare Beneficiary, you simply will not get paid. But what about demonstrating that the patient requires reasonable and necessary care for an intermittent period of time?

The best way that I have found to demonstrate that the patient is eligible for reasonable and necessary services is to write a good 486 summary. I understand that not everyone enjoys writing but anyone can put together a good summary. If your grammar and spelling stink, it does not matter. There is no eligibility requirement stating that good grammar and spelling are required to get paid. Furthermore, while templates can be a useful tool, it often happens that every single 486 summary in the agency looks pretty much identical. Templates also lead to summaries reading like this: During this episode, the patient experienced daily pain. The patient required assistance to bathe. The patient did not require assistance to transfer. The patient ambulated with an assist device.’ This ‘story’ tells me nothing that I want to read over and over again as I review 30,000 pages of documents for a single ZPIC audit.

So let’s try something different. I believe that you can write an excellent summary if you merely answer the following questions:

Why is the patient being admitted or recertified and what is the primary diagnosis?
On admission, what happened prior to admission to instigate the referral? (Patients do not just wake up and decide to join a home health care agency as though it were a gym.)
What secondary diagnoses affect the patient’s ability to participate or respond to the plan of care?
What medications does the patient take (list names only because full orders are on the 485)
What additions and deletions to the Medication list occurred during the last episode?
Is there any significant lab work or diagnostic test that was performed last episode? (Please do not write that NO lab was drawn last episode.)

Next Section – what did the patient look like last episode?

Give overall impression of neuro status. Was patient mostly oriented? Was the patient confused?
Did the patient have pain? If so describe. If the patient was taking PRN pain medication, state how much was taken and how often over the prior episode.
Did the patient have any heart or lung sound irregularities? If not, simply state that patients chest remained clear to auscultation and there were no murmurs, rubs or extra heart sounds appreciated.
Did the patient have any issues with his gut? Diarrhea? Constipation? Nausea? Vomiting? If not, state the patient experienced no GI distress. If so, try to tie it to a reason such as a drug side effect, a virus, etc.
Did the patient void okay? If incontinent, mention the skin integrity of the areas affected by incontinence.
What did the patients legs look like? Pedal pulses bilaterally? Skin flaky or peeling? Describe the patient’s gait.

Next Section – What happened that was extraordinary last episode? A fall? An illness or exacerbation? Surgery? MD visits with changed orders? Gimme something here, folks.

Next Section – What did you do about all the irregular findings?

When was the doctor contacted?
Were no orders given?
Did the MD change the plan of care?

Final Section:

What on earth do you think you are going to do for this patient?

Answer that question and you have demonstrated reasonable and necessary. Now the occasional missed weight and missed visit won’t count quite as much in a payment review. As always, we welcome your comments and emails.