Ethical reporting.

LanceCorpsman

Forum Lieutenant
120
18
18
Hypothetically...

You write a chart for a run for an elderly "fall" victim that rolled off of his bed. The pt seems to be uninjured, the pt has no complaints. The pt is atraumatic upon physical examination. The pt is on Coumadin. What should be just a lift assist turns into a transport because the wife of the patient is insisting him to go to the ER to get seen.

Your report states exactly what happened, you know the ambulance won't get reimbursed from medicare because of the circumstances.
However, a few weeks later, you see that the agency got payed by medicare for that call. It turns out the billing agent turned it into a trauma system activation and billed for it. So the PCR that i wrote and signed was altered in order to get paid (there is a box that states is I activated trauma or not, i checked no, but the one turned into medicare was checked yes..

Is this fraud? If so, should you report it? To whom?
 

joshrunkle35

EMT-P/RN
583
169
43
Hypothetically...

You write a chart for a run for an elderly "fall" victim that rolled off of his bed. The pt seems to be uninjured, the pt has no complaints. The pt is atraumatic upon physical examination. The pt is on Coumadin. What should be just a lift assist turns into a transport because the wife of the patient is insisting him to go to the ER to get seen.

Your report states exactly what happened, you know the ambulance won't get reimbursed from medicare because of the circumstances.
However, a few weeks later, you see that the agency got payed by medicare for that call. It turns out the billing agent turned it into a trauma system activation and billed for it. So the PCR that i wrote and signed was altered in order to get paid (there is a box that states is I activated trauma or not, i checked no, but the one turned into medicare was checked yes..

Is this fraud? If so, should you report it? To whom?

Well, first you should review your report with your system's QA/QI process, to ensure that you completed the report correctly and that you followed your protocols. Then, you should bring it to the attention of your supervisor, explain why you believe it to be fraudulent (assuming you are not in error), and then ask for the claim (based on your report) to be amended.

***It could be a genuine error on your part or someone else's part. Be careful before you make an allegation.

Then, if it is not resolved, contact your state EMS office, and report it. They will follow up and determine if a crime has been committed. They will fine/suspend the agency or persons responsible, and/or turn over evidence to an investigating body/prosecutor to pursue charges if there is a pattern of something more serious going on.


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akflightmedic

Forum Deputy Chief
3,891
2,564
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While you got sound advice above...you also are straying into an area that is not your lane. If you see a pattern and this one hypothetical call is an example of many in that pattern, then you need to do as above. If this is a one case jumping out for whatever reason, tread lightly and again see above advice.

Elderly patient. On blood thinner. Rolled from bed and did fall. Several high risks right there to justify transport and classification as a trauma call.

I absolutely see why a QA process and billing admin could mark this call as trauma. Yes, there should be a process where they circle back to you, present their findings and then have you tick the box...but then extrapolate that process across the board and you have a lot of people eating up time and cost for a very quick and simple fix. I am not determining their process to be right or wrong, just stating would might be a reason.
 

akflightmedic

Forum Deputy Chief
3,891
2,564
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It is interesting that you are in a position hypothetically to not only know how reports were submitted but also to know they did indeed get paid and within weeks!!! From Medicare!!! That is amazing turnaround time FYI on payment...I usually go months. How or why did you track this one hypothetical case from time of run to time of payment? Yu got mad skills bru!
 

samiam

Amazing Member
332
34
28
In michigan thats a level 2 trauma activation. The ER goes nuts...freaks the poor patient out.

Once u complete a report and digitally sign it, it should be impossible for anyone to alter it. Thats how medical records work. You may be able to add amendments or strike out but it would be obvious who did what and that it was not part of the original pcr.
 

TransportJockey

Forum Chief
8,623
1,675
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Our system (ESO) let's certain people unlock charts, but it keeps track of who and when things get unlocked and when they get relocked

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DrParasite

The fire extinguisher is not just for show
6,196
2,052
113
Elderly patient. On blood thinner. Rolled from bed and did fall. Several high risks right there to justify transport and classification as a trauma call.

I absolutely see why a QA process and billing admin could mark this call as trauma. Yes, there should be a process where they circle back to you, present their findings and then have you tick the box...but then extrapolate that process across the board and you have a lot of people eating up time and cost for a very quick and simple fix. I am not determining their process to be right or wrong, just stating would might be a reason.
Sorry, but no. What you are describing is a failure on multiple levels.

1) Billing should never modify a completed chart to ensure it gets paid (outside of adding patient demographics or billing information that may not have been available at the time of the original call, and was obtained afterwards)

2) QA should never modify a chart to "fix something" without the knowledge of the author. In the long term, the QA person does much more work, because they have to fix it every time, instead of going to the author and telling them why it was wrong, so the error doesn't occur in the future.

3) I can see your point of a QA person filling in an unchecked box, if it was an oversight by the author. I don't agree with it, but I can see your point. However, in this case, the PCR was modified, and the author's information was changed without his knowledge of consent. That's modifying the author's work, so when questions do get asked why it was a trauma activation, the author can't give a good answer, because it wasn't one. And medicare will probably come after the author first, and then the agency, investigating the discrepancy as possible fraud, especially if the hospital didn't have it charged as a trauma activation.

OP, if I was in that hypothetical position, the first person I would go to is my direct supervisor. Than we are going to have a chat with the billing supervisor (not the actual billing department staffer, but the person who actually is in charge of the entire department). If I still don't like the answers I am getting, then I'm calling the state office of EMS and letting them investigate what happened (to allow an independent party to decide if it was appropriate or not).

I'm not disagreeing that the patient could have been justified as a trauma call. Or that a trauma alert was justified. The signs were there. But that's not what happened, and having anyone who was not involved in the call modifying the documentation to include a trauma system activation is filing maliciously incorrect information, attributing it to the OP, and committing fraud for the purpose of generating additional revenue for the agency,
 
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