NC Medicaid: To Revise or Not to Revise, That Is the Question!
We think too much; thus we fail to act. That’s what Hamlet was saying during his “To be or not to be” soliloquy, right? To live or not to live? Should you bear the painful burden of life or to refuse the burden by killing yourself?
Or does the fear of the unknown (death) make us bear our painful lives? (Although Shakespeare was much more eloquent).
Medicaid providers, how many times have you reviewed your own documentation only to find accidental scrivener’s errors? The service note failed to denote the correct date of service (DOS)…the Physician’s Authorization and Certification for Treatment (PACT) form cited an incorrect Medicaid number…or the CPT code on a service incorrectly indicated an individual treatment when the service was clearly a group treatment. (People, we are NOT talking about forgery or altering dates of a physician’s signature…these things would be considered FRAUD. We are merely talking about scrivener’s or clerical errors).
To revise or not to revise…that is the question!
And what an important question it is. Because, so easily, innocent documentation corrections could transmute into documentation fraud. Medicaid fraud. Criminal investigations. Bad!
A recent Office of Administrative Hearings (OAH) decision gives us some guidance on when to revise or when not to revise.
St. Mary’s Home Care Services, Inc. v. NC Division of Medical Assistance (DMA) Finance Management Section Audit Unit NC DHHS was signed January 8, 2014, by Administrative Law Judge Beecher Gray, who was recently appointed as a Special Superior Court Judge. Believe me, we will miss Judge Gray at OAH. His Order in St. Mary’s Home Care was his parting good-bye.
In St. Mary’s Home Care, the Department was seeking a recoupment of $4,334,056.09. One of the reasons for the recoupment was that the Department contended that St. Mary’s had violated “best practices” in the way it had amended PACT forms and service notes.
A witness for the Department testified that “best practices” required St. Mary’s to either create a new document or to strike through the corrected portion, enter the correction, sign the name of the individual making the correction, and append an explanation for the correction to the document.
Judge Gray disagrees.
“The Agency’s misunderstanding of the policy and use of unpublished “best practices” as a justification for its decision is erroneous, in violation of rule and law, exceeds the Agency’s authority, and is arbitrary and capricious.”
“The Agency failed to meet its burden of proving St. Mary’s violated clinical coverage policy when it made changes or corrections to PACT form plans of care.”
So when should you NOT revise?
Obviously, do not commit fraud. But, according to St. Mary’s Home Care, slight revisions to PACT forms and service notes will not be enough to warrant an overpayment.
“Go, bid the soldiers shoot.”
Posted on March 7, 2014, in Administrative Law Judge, Administrative Remedies, Appeal Rights, Audits, DHHS, Division of Medical Assistance, DMA Clinical Policy 3C, Extrapolations, Fraud, Health Care Providers and Services, Home Health Aide Services, Home Health Services, Lawsuit, Legal Analysis, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Audits, Medicaid Fraud, Medicaid Providers, Medicaid Reimbursements, Medicaid Services, NC, North Carolina, OAH, Office of Administrative Hearings, PACT Forms, Personal Care Services, Post-Payment Reviews, Service Notes, Tentative Notices of Overpayment and tagged Administrative Law Judge, Amending Medicaid Documents, Audit, DHHS, Division of Medical Assistance, Fraud, Health care provider, Medicaid Audits, Medicaid Reimbursments, Medicaid Services, North Carolina, PACT Forms, Service Notes, Tentative Notice of Overpayment. Bookmark the permalink. Leave a comment.