Louisiana
Hospice Nurse-Administrator Charged with Conspiracy for
Altering-Falsifying Records
In 2015, Medicare audited a Louisiana hospice provider and determined that it was billing for hospice services at a level that was not supported by proper patient documentation. Consequently, Medicare reversed all of the claims for hospice services under review in that audit. Those claims amounted to $383,107.26. Medicare also issued and sent an education letter to the nurse-administrator detailing what was needed in order for the company to bill for hospice services.
Medicare performed another audit in August 2017 and requested patient documentation for the hospice care service claims submitted on 99 beneficiaries. The nurse-administrator was given the responsibility for gathering the documentation requested for these claims and providing them to the auditors. After she reviewed the company’s files on the beneficiaries, she was acutely aware that the company did not have the required records to justify its billings to Medicare for the hospice care services’ claims under review.
Court documents indicate that between August 2017 and October 2017, the nurse-administrator and other employees of the company altered, amended, and falsified patients’ records to hide the fact that the claims lacked the required medical records submitted to Medicare for claimed hospice services to the 99 beneficiaries being reviewed. One clear instance of the falsification occurred when the nurse-administrator allegedly used “white-out” on a patient’s record and then created a note on that record falsely indicating that she had treated that patient as a nurse in November 2014. The falsified records were submitted to Medicare by the nurse-administrator in order to pass the Medicare audit. In spite of the falsifications, Medicare still found the company’s records to be deficient.
If convicted, the nurse-administrator could be sentenced to a maximum of 5 years in prison, a $250,000 fine, and up to three years of supervised release, in addition to a $100 special assessment.
Compliance Perspective
Allowing claims to be submitted to Medicare without proper patient care documentation of services actually provided may result in their rejection by Medicare; or, if reimbursement has already been made and then the insufficient documentation is discovered, Medicare will require those payments to be returned, and the company could lose its eligibility under Medicare for violating the federal False Claims Act.
Discussion Points:
- Review policies and procedures regarding the Triple-Check Process for preventing the submission of false claims.
- Train staff involved in the submission of claims about the Triple-Check Process and the need for providing adequate documentation to support the level of claims submitted. Staff should report any concerns about insufficient documentation, falsified documentation, or claims for services not provided to their supervisor or through the Hotline.
- Periodically audit claims submitted to Medicare to ensure that proper documentation is being provided.
