In this episode, we delve into the often-overlooked issue of medical record falsification and its serious implications for healthcare facilities, professionals, and patients. My guest, Tracy Hunt, shares her expertise on this complex topic, examining how falsified documentation intersects with medication diversion, insurance fraud, and legal accountability.
Tracy explores the statutory definitions of falsification, potential criminal charges, and the complications of bundled medication charges in billing systems. Our discussion covers discovery methods for identifying suspicious patterns, the investigation process when concerns arise, and what happens when cases are escalated.
Whether you’re a healthcare administrator, compliance officer, or clinical professional, this episode offers valuable insights into protecting your practice, your patients, and your career from the serious consequences of documentation fraud. Join us for this important conversation about maintaining integrity in healthcare documentation and billing practices.
Transcript
Terri Vidals
Welcome back, everybody, to Diversion Insights. Today’s interview will provide insight into something different, probably for a lot of you, and that is medical record falsification and cloning. My guest is Tracy Hunt. Welcome, Tracy.
Tracy Hunt
Thank you, Terri.
Terri Vidals
Start by telling us a little bit about you and your background.
Tracy Hunt
So I’ve been doing healthcare fraud for health insurance companies for, give or take, about 20 years with a criminal justice degree and did some time in the military. So in the medical field, helping to lead to my continuation of just doing an investigation of looking at documentation and researching how providers do things.
Terri Vidals
Okay, perfect. And you’re also the Colorado president of NADDI, right?
Tracy Hunt
Yes. Yes.
Terri Vidals
Okay. All right. Shout out to nanny. All right, so we’re going to talk about record falsification. I think, you know, in many cases, when medications are diverted from patients, there’s varying levels of severity. Right. Patient harm is the most serious. But where I often hear, in addition to harm, where I often hear that somebody really lands in a lot of trouble is when they falsify by the medical records. So I want to talk about that because that can lead to insurance fraud. Right. If conviction is secured. And I think some facilities. And let’s talk about this, they overlook the necessity to correct some billing. So first, what statutes define falsification of records and can this result in criminal charges? Let’s start there.
Tracy Hunt
And I will start with the easiest first, which is, could this result in criminal charges? Yes, absolutely. There are, you know, depending on the state or county, there are a gazillion different types of laws that could be, you know, utilized. A couple of the big ones are the False Claims act, which basically just says, you know, if convicted, this is for submitting falsified medical records to secure improper payment from government programs like Medicaid, Medicare. Then you’ve got the health care fraud statute, which does make it a criminal offense to knowingly or willingly execute any type of scheme falsifying records to defraud a health care program. You’ve got the, let me think about that. The civil monetary penalties of the Social Security Act. Sorry, I had to think about that. Which just is the civil portion of submitting a false claim. Again, same thing.
Tracy Hunt
If you’re falsifying records, then your coding that you submitted for that claim is more than likely going to be, you know, incorrect as well. Then you’ve got the. What is it, the 18 US code for false statements relating to healthcare matters. So those are probably some of the big, more federal ones. And then you have, of course, whatever your local, state, or county uses as well okay.
Terri Vidals
And in cases that you see, do people often get hit for all of?
Tracy Hunt
Them, depending on the severity? They absolutely could. Okay.
Terri Vidals
All right, what about. I think more and more hospitals. I don’t know if all of them do this, but they bundle medication charges. Right. And so when I’m part of an investigation, people are like, do we need to change the billing? Oh, well, it’s bundled. So let’s talk about that. If it is bundled, and for those that are not familiar with that, this not an itemized list of charges for their medications. Right. So it’s just kind of a one group fee that groups into it. So the meds are put in there. If they do have a bundled approach, what should a place do if they find that somebody has falsified records? This is just on the institution’s side. Of course, the person can’t take it back. But what should the institution do and should they.
Tracy Hunt
Well, and typically, you know, when they. If you’re seeing just. We’ll just call it a generic, you know, bill, they could be asking the facility or institution for an itemization. You know, that. And that includes, you know, all pharmaceuticals, but that could include anything that they’re bundling, whether it’s labs, X rays, you know, those kinds of things. They could absolutely. That facility should be able to give them an itemization of what was given or done on any specific day. And if they. They can’t, then that’s definitely a suspect facility that you want to look at a little bit more because, you know, they obviously need to account for that for cost, but they should be also billing it, you know, on a daily basis or at least a weekly basis, depending on what the, you know, patient’s in for.
Terri Vidals
So, but if it’s a bundled fee, is it. And if it’s a bundled fee and I have diverted and I have charted to hydromorphaline syringes for the patient that the patient never got. But it’s a bundled fee, so it doesn’t matter whether I chart 2 or 10. It’s the same price. Right. Ultimately, from an insurance perspective, is that correct?
Tracy Hunt
It could depend. Because typically, even with bundled fees, you still can have an itemization. Right. And we’ll just make it up. Say they bundled that they gave a patient 50 Tylenol, you know, within that documentation, it should say the patient received, you know, over a course of a week, 50 Tylenol. Bundled or not, you should still see that all of that is accounted for within the documentation.
Terri Vidals
Okay. Does that. If they really only received 20, though, and not 50. But the charge doesn’t change. It’s just the itemization.
Tracy Hunt
Right. And at that point, that’s more of a. An education. If it’s, you know, if we’re going to pay you $100 for 50 Tylenol regardless, you know, that would still be an education back to that facility to say, hey, yes, even though this is a flat fee, so to say, and we’re paying you for one cost, but that cost is typically going to say, and I’m again making it up, you know, 1 to 50 is this much, 50 to 100 is this much.
Terri Vidals
Okay. So even if it’s bundled, there’s a point at which if they cross over into the next range, then it does result in a higher charge to the insurance. Okay.
Tracy Hunt
All right.
Terri Vidals
And so what would your recommendation be? If a hospital is in the middle of an investigation, they determine that there has been falsification of records charting on the EHR that meds were given that weren’t really given, then they should go in and look at that itemized and remove the ones that they know definitively were not given.
Tracy Hunt
Correct.
Terri Vidals
All right, so the healthcare professional that has done the fraudulent charting, it’s too bad for them already they can’t change that right now. The facility has attempted to correct so that they themselves are not accused of fraud. How does this play out for the institution? I’m used to hearing these cases, you know, whether it’s a diversion case and the DEA comes in and they find all kinds of things, and then the facility gets hit with this, these huge penalties, fines. Does it work the same way through insurance? Is an institution on the hook for charting fraud as well as a person?
Tracy Hunt
It could be, yes. Because in theory, they should have some type of, you know, quality assurance program set up, you know, and it doesn’t have to be, you know, everybody looks at every record, but depending on the type of facility and how large, they should have some type of QA program set up to where they’re, you know, auditing notes to make sure, you know, everything was documented and what, you know, what was billed out on that specific day or week, month, whatever that case may be. And especially if they’re looking at a, you know, specific healthcare person, whether it’s a nurse or a doctor, you know, they could absolutely go and, you know, grab all of those records.
Tracy Hunt
Sorry, I started to think of my word there for that person to see how they’re documenting compared to what they, you know, were billing out or diverting potentially.
Terri Vidals
Yeah. I did have a case once where it was the billing department that called me and said, why would you know, I don’t even remember what the circumstances were, but it was a good catch from them. And it’s like, yeah, you’re right, that doesn’t quite make sense. And so I wish I could remember what it was that alerted them. Right. It wasn’t just a dose of an opioid. Obviously those happen all the time. But something piqued their interest and they were spot on. Maybe it was a duplicate charting or something. They knew that these were too close together. But anyway, it was the billing department. So they were clearly looking at, you know, what was being built out.
Tracy Hunt
And I mean, and that’s good for them because sometimes, you know, I know I have friends that do QA for facilities. And, you know, if you’re only just looking at maybe a specific day or two, you may not catch it. But a billing department is a great area because they’re looking at everything that was done and doing that billing. And that is a great find. And those are your key people for definitely education and training.
Terri Vidals
Definitely need to loop them into what is diversion and watch for it. Yeah, definitely. So what are the various methods of discovery that you and your team employ? And perhaps then the institution themselves, as part of their qa, can kind of keep their eye on those things too. But how do you go about looking.
Tracy Hunt
So kind of like we just talked about, you know, really, it’s kind of a QA of, you know, if we’re looking at it from a health insurance aspect, you know, it may be okay. I’m going to ask, you know, ABC Facility for all medical records for Jane Doe. And, you know, I could do it patient by patient or maybe we do look at it for a specific time frame. You know, it just kind of depends on what the initial allegation is. You know, is it against the doctor or is it against the facility? You know, it just really kind of looks at what was that allegation and what we might want to pull. And you know, we may do, you know what, that’s what we call a post paper.
Tracy Hunt
Looking at it after the fact that there are times that we put them on what we call prepay, which is we’re going to review all documentation before we pay them anything.
Terri Vidals
Okay.
Tracy Hunt
You know, in that way that gives us that better look overall at that patient or, you know, it’s going to be patient regardless, but potentially at that, you know, facility or that provider as well to see what they actually Documented versus what was billed.
Terri Vidals
Okay. So you will have cases where you. Before you pay anything, you just review it. But then also, if something is brought to your attention through some sort of complaint or what have you, then you do a post look, correct?
Tracy Hunt
Yeah.
Terri Vidals
Right. Okay. And if you find something that you suspect is not looking. Right. What is a typical investigation process involved?
Tracy Hunt
So typically, we’ll, you know, if we kind of. We’ll just go with we got the allegation from someone else just to kind of make it a high level, easy. We’ll pull some data on that provider or that facility. Just kind of looking at how they bill overall. You know, does anything look, you know, out of whack, you know, compared to what they should be billing against their peers, you know, and if it looks like it’s, you know, pretty normal, then we’ll start, you know, potentially patient interviews. You know, especially if we did get an allegation, you know, we may call a handful of patients and, you know, say, hey, just, you know, kind of checking in to see, you know, what happened when you were at the hospital, you know, for these five days, you know, how was your care? How was your treatment?
Tracy Hunt
You know, what did you have done? And just more of a. Kind of a casual conversation because, you know, you don’t want to let that patient know, hey, you know, we’re expecting, you know, John Doe or.
Terri Vidals
Yeah.
Tracy Hunt
Of something. And, And a lot of times we’ll just, you know, kind of preference that conversation with them of, you know, we’re just doing a quality audit to say, you know, hey, how’d everything go? Would you have done? You know, and sometimes, you know, patients are really good about letting you know what they did, and some are very generic, so you have to kind of probe a little bit more of, you know, hey, did you really get those, you know, 50 Percocet in that three days? You know, and they’ll be like, what, are you kidding? And you’re like, oh, oh. You know, and then, of course, you know, I don’t want to say playing it off, but, you know, trying to backtrack just that smidgen to say, oh, sorry, I didn’t mean 50. I meant five.
Tracy Hunt
You know, because then they do start, you know, kind of freaking out. And so you just kind of have to, you know, play with it based on how that person is when you’re. When you’re having that conversation. And then again, like we said, we’ll do, like a medical record review of, you know, everything that they had done. If it was you know, maybe they saw a provider across multiple hospitals which would be, you know, you’d be like, well, why did you go to five hospitals in, you know, three days? You know, you’ll try to get that documentation from all the facilities to really see and just kind of bring it again back to that patient in a casual conversation and, you know, hey, you know, did you go here? I mean, could it be likely? Absolutely. Is it? Probably not. Yeah.
Tracy Hunt
And then we’ll just, you know, depending on how the case is, you know, we could even potentially do an on site audit for a provider and just, you know, say, hey, well, you know, send them the letter. Hey, we’re going to be there on this date, you know, based on contracts. We’re going to be looking at, you know, potentially 50 records. So they know that, you know, that we’re coming and to be expecting that. And, you know, more often than not, we will kind of give them the heads up of what patients we’re going to be looking at for medical records.
Tracy Hunt
But we, you know, again, depending on contracts, since we are an insurance company, we’ll, you know, we have to give them so much time, notice that we’re coming and we will typically try to do that as close to the date that we want to get there as possible. So there’s a less likelihood of any falsification or creating medical records to substantiate what they build.
Terri Vidals
Yeah. So I’m curious, how often do you. I mean, I guess I don’t think of a legitimate facility. You know, it’s a true medical center and they’re doing business. Obviously they’re not perfect and there could be things that happen and there could be people within the institution that are charging for what they shouldn’t charge and it gets past the billing. I get all of that. But how often does it happen that a legitimate organization has to be audited and you find things. And I guess I’m comparing that to. I recently had a friend of mine tell me that she got a letter in the mail about her insurance, was paid a certain amount of money for this, something. She’s like, I have no idea what they’re talking about.
Terri Vidals
And then it just so happened that a friend of hers that same day said, look what I got in the mail that said my, you know, Medicare, I think it was paid for, Medicaid paid for. And it’s like, you know, two of us, same procedure, same charge, same.
And it’s like, okay, this isn’t right. So they reported it to the local office and they said, oh, yeah. And by the time we catch these people, they fold it and they’re gone. So is the majority of your stuff that you find places like that are really nefarious and they’re all simple just to bill and false billing or legitimate institutions.
Tracy Hunt
That’s a tough one because of course, it depends on the part of the country. You know, we do have the hotspots for that exact scenario, you know, but there truly are some facilities that, you know, want to do the right thing and, you know, had no idea that their builder was doing XYZ or, you know, the nurse or provider was billing xyz. You know, where it kind of comes to be a little sticky and then they get, you know, into more trouble is that, you know, ultimately they’re the ones submitting the claims and they’re responsible for what goes out. Right. So it’s really. It can get sticky. And, you know, like I said, we’ve had some providers that were like, oh my gosh, I had no idea that we’re honestly, legitimately didn’t realize that they were billing wrong codes.
Terri Vidals
Sure.
Tracy Hunt
You know, they were like, you know, it was one of those, well, you know, I went to a conference and they were talking about, you know, we should be billing, blah, blah, and you’re like, well, you can. However, your documentation doesn’t support that kind of, you know, code. And so a lot of times when we’re doing those audits, we try not to tell the provider upfront what code they should be billing, other than, you know, your documentation isn’t supporting the code you are billing. You know, but there will be times when it is a true legitimate that, you know, we work with them to identify what the appropriate code should be without us telling them, because that’s not really our job. You know, that’s ultimately their job because they’re the ones that. That do the billing.
Terri Vidals
Yeah, that makes sense. What about in retail pharmacies? Is it mostly. I mean, do you see claims resulting from thinking if it’s a diversion thing, it probably isn’t a records falsification from an insurance perspective at that point. Well, unless they’re handing things to not patients.
Tracy Hunt
Well, and a lot of times with those, it’s. I mean, you could call it falsification. A lot of times it’s not. They don’t even have documentation. They’re just, you know, they’ve acquired insurance information from, you know, 550,000 people and they just bulk submit claims maybe for a week or two and stop. They’ve got their Money, they shut down and then they move on and, you know, open up a new tax ID and PI, you know, and do the same thing.
Tracy Hunt
And those types of places go from, you know, can range from, you know, they’re just going to do it for, you know, months to years on end, smaller dollar, hoping never to get caught, to those that bill that, you know, high dollar, you know, chemo or, you know, whatever those high dollar medications are for a short time just to get the money, then shut themselves down and move on.
Terri Vidals
Sure. Okay. All right. So to circle back to the healthcare professional within a hospital or surgery center that is diverting and is using, doing it by way of falsifying the records is these cases where everything makes sense. Right. They’ve dispensed it, they’ve charted it as administered and you know, takes a while for people to kind of figure that out. And they have no smoking gun because they’re meticulous in their charting. But their amounts make you pretty sure that this doesn’t make sense because nobody else gives this much. And you know, this patient got way more. There is most likely falsification of records. The hospital can’t prove it if the person doesn’t admit it. Is there anything that you would recommend that should be done from the facility standpoint and those records?
Tracy Hunt
Gosh, I’m thinking really from. And I know, you know, granted after the fact, by the time they’re catching it’s going to be a little more difficult, but it really is at that point, you know, talking to that patient. Right. Because they’re the ones that would have gotten that medication. And then, you know, talking to those that were around during that time, you know, obviously shift to shift. Maybe not necessarily a surgery center, but at least if you’re in a larger facility, shift to shift, you know, Nurse Doe would know if, you know, patient Smith was really hurting or all of a sudden got, you know, better, you know, they should be able to identify those differences within the staff and within talking to the patient themselves. Yeah.
Terri Vidals
So it requires real time identification and then that is your proof, talking to the patient that they didn’t get it, essentially. And you know, I have recently actually a couple of cases that have come across my desk recently. It was the patient, they got on their, my charts and they looked and they’re like, I did not get that meant. And I was at a hospital last week doing a gap assessment and first time I have seen this really neat board that they have up in every patient’s room. And it’s connected to the ehr and it tells them when the last time they got the pain medication. And the patient can see it. I mean, it’s right there on the board.
Terri Vidals
And so of course the staff can see it too, when you’re going to go in to give it, which I thought was really neat for patients that want to keep track that, you know, is a diversion mitigation technique because it’s just out there for the whole world to see that they just got that med and then incorporating those patient rounds and kind of similar to what you were saying about you call the patient and you’re, you know, asking them questions. But I always encourage them, not just your generic patient rounds. How are you doing? How’s your pain control? You know, it’s very targeted. Oh, I see here you got such and such for your back pain about an hour ago. How did that work? And then lo and behold, the patient sometimes will say, I didn’t have any back pain.
Terri Vidals
And then that’s when you get it. So incorporating that into just the routine of the day of the shift.
Tracy Hunt
And I noticed when some of our investigations, when we’ve done some facilities kind of again after the fact, kind of like what you’re saying is targeting it with, oh, you got that, you know, that Percocet, you know, an hour ago, you know, how did, you know, how was that compared to when you got the, you know, Percocet six hours ago? You know, when you’re targeting again a specific person and what we’ve seen is, oh yeah, you know, that middle of the night, Percocet wasn’t, didn’t seem to help nearly as much until I got my next dose, which would have been shift change, you know, identifying that kind of thing too. And you’re like, no, I, I, you know, I felt like I was taking a good old Tylenol and not a, you know, a Percocet.
Terri Vidals
Yeah, yeah, no, that makes sense. You know, we didn’t talk about cloning, so I think cloning is one of those things I was not familiar with. And I think it’s a way that you identify potential fraud in a chart. Right. So can you just explain to the listeners what cloning is?
Tracy Hunt
So cloning is, it’s similar to a falsification. But really what you’re seeing is if it’s the exact same statement, vital signs, just the same exact information, visit after visit with no changes. And you know, we see a lot of, a lot more of that within, you know, non facility provider cases. I can say I Probably haven’t seen that in any facility that I’ve looked at, but a lot more non facility. You know, those that are just going in to get maybe a quick visit or a medication refill, and, you know, whether it’s the provider or the front desk, whatever, just copies exactly what was on the last visit, and all they do is change the date. Sure, yeah, change the date. You know.
Terri Vidals
Wow. Yeah, yeah. And there’s. I have a podcast coming out soon. Hasn’t been published yet, but we kind of talked about that. It’s a gentleman. That helps physicians just, you know, mitigate their risk for their legitimate positions and to keep the DEA out. Right. And it’s all about, you’ve got to write your notes and you’ve got to talk about the visit and you’ve got to, you know, so, yeah, you would expect things to change from business to visit.
Tracy Hunt
I mean, that’s. Yeah, that’s what we say all the time, you know, and providers get all mad at us. It’s like, you know, you may have. And, you know, you may have done that heart surgery, but what you build was a heart surgery plus a, you know, a gastric bypass, you know, well, in order. And a lot of times they’re like, well, I have to do this to get to that. Well, you didn’t document that. I understand. You may have to. But, you know, again, it’s not documented. It didn’t happen. Sure.
Terri Vidals
Yep. That’s the. That’s the key right there. Okay. All right. Thank you very much, Tracy, for your time. This was interesting. For me, it’s a space that I’m not as knowledgeable in, for sure. And so reminder, everybody out there, make sure your
billing department understands what diversion is, and you can engage them in that monitoring piece of it because they. They see all of those. All of those myths.
Tracy Hunt
Yeah.
Terri Vidals
All right, thank you, Tracy.
Tracy Hunt
Thank you.
