Puerto Rico Dialysis Provider Did Not Comply with Medicare Requirements for Beneficiaries
Failure to comply with Medicare requirements for documentation that supports billing for healthcare services may cause the submission of false claims in violation of the False Claims Act
Compliance Perspective – Medical Records Documentation
Policies/Procedures: The Compliance and Ethics Officer with the Administrator will review policies and procedures for adequately supported medical records, comprehensive resident centered care plans, and appropriate physicians’ orders.
Training: The Compliance and Ethics Officer and the Director of Nursing will ensure that staff are trained in understanding and implementing the policies and procedures related to properly supported medical records, comprehensive resident centered care plans, and physicians’ orders.
Audit: The Compliance and Ethics Officer should personally conduct an audit to determine if the policies and procedures regarding medical records, residents’ care plans, and physicians’ orders are being followed.
The Office of Inspector General (OIG) found in an audit that a Puerto Rico dialysis provider failed to comply with Medicare requirements in these three areas: (1) beneficiaries’ medical information was not adequately supported, (2) plans of care or comprehensive assessments did not comply with Medicare requirements, and (3) physicians’ orders did not meet Medicare requirements.
The errors are reported to have occurred because the provider’s inadequate electronic health records system and related procedures were unable to ensure that certain ESRD (end-stage renal disease) measurements and comorbidities documented in beneficiaries’ medical records were correctly reported on their associated Medicare claims. While the provider had policies and procedures in place to ensure that dialysis services were properly ordered and documented, they were either not followed or did not meet Medicare requirements.
The OIG report estimated that the provider received unallowable Medicare payments of at least $403,000 for non-compliant dialysis services that did not comply with Medicare requirements.
The OIG recommended that the provider refund an estimated $403,000 to the Medicare program, and made a series of recommendations to strengthen the provider’s policies and procedures for ensuring that dialysis services comply with Medicare requirements.
