Home Health & Hospice Week

Fraud case highlights important compliance aspect of OASIS.

You could lose hundreds of dollars per episode if your staff fills out OASIS incorrectly, but you could lose your agency if you correct those assessments the wrong way.

Case in point: Merigrace Orillo, co-owner and operator of Chalice Home Healthcare Services Inc. in Chicago, has pled guilty to a scheme that included changing OASIS forms. The changes "made Chalice's patients appear to be sicker than they actually were and in need of greater care than they actually required," says a release from Patrick Fitzgerald, U.S. Attorney for the Northern District of Illinois.

Orillo conducted the fraud with her husband Virgilio Orillo, the original indictment said. But he died last August.

Reviewing OASIS for accuracy isn't unusual. "A number of HHAs have their OASIS forms reviewed and revised based on their understanding of better or more informed coding and regulatory knowledge," notes financial consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas.

But how you do it can make the difference in whether authorities see it as fraudulent upcoding or a legitimate quest for OASIS accuracy. A big no-no is making the changes without the assessing clinician's knowledge or consent.

"Normally, if an error is identified through audit or review, the individual who made the original entry into the patient's record would, whenever possible, make the necessary correction by following agency policy," the Centers for Medicare & Medicaid Services says in the July 2011 Quarterly CMS OCCB questions and answers.

But your correction policy could allow the auditor to contact the clinician who made the entry to discuss the discrepancy and make the correction. If your correction policy allows this method of making a correction, be sure to document who discovered the error and the date and time of the discussion with the assessing clinician who agrees that it was an error, CMS instructs.

Don't think your nurses will stay quiet on the subject if asked by prosecutors. Nursing message boards are filled with threads about nurses who are outraged over supervisors changing their OASIS assessment answers (even when justified) and worried about their own fraud liability.

What Do You Do When The Clinician Quits?

Sometimes changing an OASIS without the clinician's consent is OK, though.

Last year, an HHA asked CMS about this scenario: "Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. This clinician no longer works for our agency, so we cannot contact her about the error. Can this OASIS change be made by the director of nursing without speaking to the clinician?"

Two factors are important to point out in a scenario like this, said nurse and OASIS expert Annette Lee with Redmond, Wash.-based OASIS Answers during the July 2011 OCCB Quarterly OASIS Update audioconference. First, this situation describes a true OASIS scoring error -- not a situation where someone is questioning what was reported. Second, the assessment was complete.

There's no disputing the fact that the patient had an ostomy, based on the medical record. But for some reason, the assessing clinician incorrectly reported it as a surgical wound in M1340 despite OASIS guidance which indicates that ostomies aren't considered surgical wounds for this item.

This is a situation in which you'll need to refer back to your agency's correction policy, Lee said. But before you can do that, you'll need to make sure that your agency has a correction policy and that the policy follows the regulations set out by CMS.

Tip: Corrections such as the one discussed in this scenario do not impact M0090 -- Date assessment completed.

In this situation, the assessing clinician is no longer available, so the clinical supervisor or quality staff can make the correction. They should follow agency correction policy and document why the original assessing clinician isn't available to make the correction as well as how the error was discovered and validated, CMS says.

Remember: When you make corrections to assessments that have been submitted to the state, consider the impact on the plan of care, HHRG, plan of treatment, and RAP. Make corrections to those documents and billing as appropriate, CMS says.

Meanwhile, the OASIS changes aren't the only charge in the Chalice case. Orillo also pled guilty to helping her husband pay a kickback to a Chicago physician in return for referrals.

Don't be surprised to see a trend in home care prosecutions, Boyd says. Prosecutors may uncover a blatant charge such as the kickback in this case, then go after OASIS changes in further investigation.

Note: For guidance on establishing a correction policy, see www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/scletter01-12.pdf.