Q: When does a Minimum Data Set error become fraud?
A: Fraud is deception intended to result in financial or personal gain. It includes false representations, false statements or concealing information. The Office of Inspector General maintains a website and hotline where the public can submit complaints and report suspected fraud.
The RAI User’s Manual offers definitive guidance. To seek payment, conditions must be coded accurately — which includes meeting all criteria from the instructions. If circumstances do not satisfy all criteria, do not code them.
For example, if a resident does not satisfy all four criteria for isolation, knowingly coding isolation to achieve a higher case-mix classification would constitute fraud. Alternatively, asking a physician for an unsupported diagnosis to exclude the resident from a quality measure could also be fraud. Both scenarios involve presenting false representations for gain.
The MDS attestations require individuals coding the MDS to sign. The RAI manual states, “Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response.” It warns those signing that “the information you entered on the MDS, to the best of your knowledge, most accurately reflects the resident’s status. Penalties may be applied for submitting false information.”
Human error occurs and coding discrepancies do happen. When an MDS inaccuracy emerges, follow the RAI User’s Manual instructions. It requires modification of that MDS within 14 days of discovery. Concealing errors to avoid repayment would be another form of fraud.
Whether an intentional falsehood or a concealed mistake that goes uncorrected, presenting false information for gain constitutes fraud.
Amy Stewart, MSN, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, is vice president of education and certification strategy for AAPACN. Send her your nursing questions at [email protected].
From the July/August 2023 Issue of McKnight's Long-Term Care News
