How to Handle Allegations of Fraud and Abuse from Patients and Their Families

orioleHome care providers of all types; including home health agencies, hospices, private duty agencies and HME companies; that receive any monies from federal or state programs; such as Medicare, Medicaid, Medicaid waiver, or Tricare; must make fraud and abuse compliance a top priority. As patients and their families become more familiar with fraud and abuse in the Medicare and Medicaid Programs and in other state and federal health care programs, the number of communications related to this topic from patients and their families is likely to increase. A crucial question for managers is how to handle these allegations.
Needless to say, allegations of fraud and abuse from patients and their families should be treated very seriously. Managers who receive such complaints should have two primary goals: (1) providers must demonstrate adherence to their internal compliance plans, and (2) staff must also conduct a thorough investigation so that complainants are satisfied that there is no need to go to outside regulators and investigators because all that should be done has already been done internally.
The time for providers to wonder whether they should have Fraud and Abuse Corporate Compliance Plan has long gone. Providers are, quite simply, playing with fire when they do not have such Plans in place and effectively implemented. Among other things, Corporate Compliance Plans should specify necessary steps to conduct an investigation of reports of possible fraud and abuse. At a minimum, Corporate Compliance Plans should specify a time limit for completion of investigations. Under most circumstances, investigations must be completed within sixty days in order to meet applicable requirements for self-disclosure, if necessary.
Corporate Compliance Plans should also require completion of written reports within the time frame specified above. Written reports of investigations should include, at a minimum: (1) a description of how the alleged fraud and abuse was identified and the origin of the information that led to the disclosure, and (2) a detailed description and chronology of the investigative steps taken including:
  • A list of all individuals interviewed, the dates of those interviews, the subject matter of each interview, business and home addresses and telephone numbers of each witness interviewed, and the positions and titles in the organization, both currently and during the relevant time period
  • A description of the files, documents, and records reviewed
  • A summary of auditing activity undertaken and a summary of the documents relied upon in support of cost impact determinations, if any
In addition to compliance with internal Compliance Plans, providers should also take practical steps to ensure that patients and their families who make allegations are satisfied that sufficient internal steps have been taken so that they are not tempted to go outside provider organizations to investigative agencies. It is at this point that it is necessary to sound a strong note of caution.
The experience of many providers has demonstrated that allegations of fraud and abuse from patients and their families may often be based on a lack of understanding of reimbursement systems, inaccurate memories of events and/or applicable standards of care. Instances in which patients and their families claim that they never received services are classic examples of the need for caution.
While providers must take allegations of fraud and abuse very seriously, they must also keep an open mind until investigations are complete. Managers must remember that staff and contractors have the right to a fair, impartial investigation, as outlined above, before adverse action is taken against them.
Perhaps the real bottom line, regardless of conclusions reached, is to satisfy patients that such allegations are treated seriously and thoroughly investigated in order to avoid additional action by patients and their families.
©2020 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.




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