Tightrope Walking: Correcting Errors in Health Care Documents After the Fact

People screw up. We are human; hence the term, “human error.”

But how to handle said mistakes in health care records after the fact, which could be the target in a Medicare/caid audit?

This is a very important, yet extremely “fine-lined” topic. Imagine a tightrope walker. If you fall off one way, you fall to the abyss of accusations of fraud. You fall off the other way and you fall into the ocean of the False Claims Act. Fixing document errors post date of service (DOS) is a fine line with catastrophic consequences on both sides.

tightrope

In NC, our administrative code provides guidance.

“SECTION .1400 – SERVICE RECORDS
10A NCAC 13J .1401 REQUIREMENT

(a) The agency shall develop and implement written policies governing content and handling of client records.

(b) The agency shall maintain a client record for each client. Each page of the client record shall have the client’s name. All entries in the record shall reflect the actual date of entry. When agency staff make additional, late, or out of sequence entries into the client record, the documentation shall include the following applicable notations: addendum, late entry, or entry out of sequence, and the date of the entry. A system for maintaining originals and copies shall be described in the agency policies and procedures.

(c) The agency shall assure that originals of client records are kept confidential and secure on the licensed premises unless in accordance with Rule .0905 of this Subchapter, or subpoenaed by a court of legal jurisdiction, or to conduct an evaluation as required in Rule .1004 of this Subchapter.

(d) If a record is removed to conduct an evaluation, the record shall be returned to the agency premises within five working days. The agency shall maintain a sign out log that includes to whom the record was released, client’s name and date removed. Only authorized staff or other persons authorized by law may remove the record for these purposes.

(e) A copy of the client record for each client must be readily available to the appropriate health professional(s) providing services or managing the delivery of such services.

(f) Client records shall be retained for a period of not less than five years from the date of the most recent discharge of the client, unless the client is a minor in which case the record must be retained until three years after the client’s 18th birthday. When an agency ceases operation, the Department shall be notified in writing where the records will be stored for the required retention period.”

What NOT to do:

  • Erase notations and write the revision
  • Add a check mark that was not previously there
  • Forge a staff’s initials
  • Back date the revision

When it comes to alteration of medical records for Medicare/caid patients after the DOS, you are walking on a tightrope. Catastrophe is below, not a net. So tiptoe carefully.

Call an attorney with specific questions.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on October 30, 2015, in Administrative code, Audits, Credible Allegations of Fraud, Criminal Medicaid Fraud, DHHS, False Claims, False Claims Act, Fraud, Gordon & Rees, Health Care Providers and Services, Knicole Emanuel, Legal Analysis, Legislation, Medicaid, Medicaid Advocate, Medicaid Attorney, Medicaid Audits, Medicaid Billing, Medicaid Fraud, Medicare, Medicare Attorney, Medicare Audits, Medicare RAC, NC, North Carolina, Office of Administrative Hearings, Post-Payment Reviews, Prepayment Review, Provider Medicaid Contracts, RAC, RAC Audits, Regulatory Audits, Tips to Avoid Medicaid Recoupment and tagged , , , , , , , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 7 Comments.

  1. These documentation policies are the key elements that would prove some provider agencies actually ignore them when deciding to fabricate documentation or commit fraud. No “late entry” tags for the few they could keep assets for due to outlined timeframe in the records manual/records retention and disposition manual. For example, when they choose to draft 300-30,000 service notes for various consumers/clients/beneficiaries, for dates from two years ago. They win because no auditor has reviewed the “true original document” that if drafted in ms office word will show its a false claim with timestamps also know as the date of creation. Modification or last printed details are recorded as well. (I love software that is informative but of course you cannot expect someone to think outside the box and know to look for that). The service note viewed is far from an actual account of the service. It never happened as stated or in some cases not at all. Undortunately the auditors like PCG whom I have personally encountered are not analyzing the “true original” electronic medical or health records to prove its fabricated. The manual needs an upgrade to cover the potential fraud technology today contributes to. NC in serious need of information system analysts? I have theory I have not tested as well and that is that there is a strong probability they have frabricated without a trail to detect it so it’s possible NC have a low percent chance of recoupment. WHEN I THINK OF THE MILLIONS SPENT TO DETECT AND COMBAT FRAUD… SMH

  2. Btw! Great blog for NC Provider Agencies!!! Raising awareness! Two thumbs up!

  3. Revised comment:

    These documentation policies are the key elements that would prove some provider agencies actually ignore them when deciding to fabricate documentation or commit fraud. No “late entry” tags for the few they could keep assets for due to outlined timeframe in the records manual/records retention and disposition manual.

    For example, when they choose to draft 300-30,000 service notes for various consumers/clients/beneficiaries, for dates from two or more years ago. Provider agencies win because no auditor has reviewed the “true original document” that if drafted in ms office word will show its a false claim with timestamps also known as the date of creation. Modification, time editing, or last printed details are recorded as well.

    I love software that is informative but of course you cannot expect someone to think outside the box and know to look for that.

    The service note viewed is far from an actual account of the service. It never happened as stated or in some cases not at all. Unfortunately the auditors like PCG whom I have personally encountered are not analyzing the “true original” electronic medical or health records to prove its fabricated. The manual needs an upgrade to cover the potential fraudulent activity technology today contributes to.

    NC in serious need of information system analysts?
    I have a theory I have not tested as well and that is that there is a strong probability they have fabricated without leaving a trail to detect it, so it’s possible NC has a low percent chance of recoupment.

    More than initials are being forged! I hope lawyers like yourself are not providing legal representation for agencies doing such. WHEN I THINK OF THE MILLIONS SPENT TO DETECT AND COMBAT FRAUD… SMH

  4. Reblogged this on medicaidlaw-nc and commented:

    Important issue!! I posted it on Friday, so for those who missed it…(because your weekends started early)

  5. In Robeson County, NC the majority of these behavioral healthcare providers are committing fraud while laughing at the state and their contract auditors. As a taxpayer I want to see auditors do their jobs by entering these facilities and actually looking for the date of creation on the providers computers. What is so hard about doing this? Including this in all audits will ensure that the state has the evidence they need to get taxpayer money back. Allowing these providers to get away with this (with the help of dirty lawyers) is ridiculous and it is killing the state’s budget. I challenge all auditors to check for the date the document was created. Documents like therapy notes, pcps, assessments etc….if they were created in Microsoft Word a simple click will allow auditors to see when the document was actually created. They will be shocked to see that it was done long after the fact, which means FABRICATION. Get taxpayer money back or resign. I certainly hope our state government is not assisting these provider agencies with covering up their fraudulent activity.

    • Janella23,

      Exactly, I am trying to figure out how an expert technology professional such as Shaun Barry could not point out this important factor as a potential method agencies would use to prevent being caught. They are using basic computer skills to do this without a degree in the technology field. How can anyone with such a degree or training still be employed to audit any kind of company when fabrication is used on a daily basis by healthcare professionals and other professionals as well. Look Program Integrity/ DHHS, no one is asking that you make it point to blast them in a news broadcast or newspaper headline but at least show us that NC taxpayers won’t be filling up the pockets of a business owner(who more than likely misclassifies workers, along with scamming Medicare/caid, and the IRS) by allowing them to get away with false claims. I mean with what they paid PCG and Mr. Barry I could have been paid less than that and showed them their millions in recoupment. In Robeson county the MCO/LME and most agencies are committing fraud. The employees at these places are furious for not being paid on several occasions but how is that? Are they operating the business off of monetary donations from the competition, local businesses like food lion or I.O.U’s? I don’t think so! After some gained experience in this matter I think our state agencies in Raleigh do not care/ some individuals are bought and paid for on the issue. So I sit back and watch the chips fall as they may…..

      • Can we get a post payment review audit that determines if the records retention and disposition policy procedure is being executed as mandated? Or call it a records retention and disposition audit only… Who cares what it’s called but I bet you will have more than a few giving excuses like catastrophic weather, flood, or the most common is blaming ” disgruntled employee” or “lazy employee.” Another thing I would love to know is if anyone has done research or surveys that would possibly show how parents have applied for Medicaid for their families but did not answer “yes” to the question that asks if the child will be needing mental health/substance abuse/developmental disabilities services. What about telling their family doctor “yes” to the question. I bet a majority of the patients these agencies are serving are filled with these kids that parents initially said “no.” They became a client by workers going out into the community offering a variety of thingslike baby sitting other than treatment services. If you are providing services to consumers great but don’t try to afford your mansion, BMW, Boat or yacht,& designer bags or clothes with money that could have been used in the budget for kids with autism. Most of these people I would not let give my dog treatment for depression. Their business ethics for personal gain show they need services too. Who’s providing the treatment services to the professional population in NC? You’ve got some work to do…..

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