Home healthcare companies give
home patient care by skilled professionals, such as: registered
nurses; psychiatric nurses; physical, occupational and speech
therapists; certified nursing assistants; and social
workers. These companies, which provide personal care
services (PCS) in the home, must follow specific Medicare and
Medicaid rule and regulations in order to bill those government
payors for the services rendered.
do not, they may be violating the False Claims Act and may be sued
in a qui tam action for such violations.
One such rule requires 90 -day
supervisory visits. Specifically, Medicaid's Clinical
Coverage Policy 3L, 7.10b: Supervisory Visits in Beneficiary
Private Residences, requires the following:
The In-Home PCS Provider shall ensure that a qualified RN
Nurse Supervisor conducts a RN Supervisor visit to each
beneficiary's home location every 90 calendar days. Two
visits within 365 days shall be conducted when the In-Home Aide is
scheduled to be in the home. The RN Supervisor shall:
- Confirm that the In-Home Aide is present or has been present as
scheduled during the preceding 90 days.
- Validate that the information documented on the aide's service
log accurately reflects his or her attendance and the
- Evaluate the In-Home Aide's performance.
- Identify any changes in the beneficiary's condition and need
for PCS that may require a change of status
- Request a change of status review if the beneficiary's plan of
care exceeds or nolonger meets the beneficiary's needs for
- Identify any new health or safety risks that may be present in
- Evaluate the beneficiary's satisfaction with services provided
by the In-Home Aide and the services performed by the
home care agency.
- Document all components of the supervisory visits to
include the date, arrival and departure time, purpose
of visit, findings and supervisor's signature.
- Review and validate the in-home aide's service records to
- A. Documentation of services provided is accurate and
- B. Services listed in the plan of care have been
- C. Deviations from the plan of care are
- D. Dates, times of service, and services provided are
documented on a daily basis;
- E. Separate logs are maintained for all
- F. All occasions when the beneficiary was not available
to receive services or refused services for any reason
are documented in the service record, including the
reason the beneficiary was not available or refused
- G. Logs are signed by the In-Home Aide and the
beneficiary after services are provided on a weekly
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These "Visiting Nurse" supervisory visits must be documented
every 90 days by a qualified Registered Nurse and the documentation
must attest that each of the requirements of Clinical Coverage
Policy 3L 7.10b was fulfilled. The immediate penalty for
non-compliance with Clinical Coverage Policy 3L is the repayment of
all funds to Medicaid/CAP for the entire 90 day service period for
all services rendered without the required supervisory nurse
Thus, per DMA Clinical Coverage Policy 3L 7.10(b), an RN
supervisory must "confirm that the In-Home Aide is present or has
been present as scheduled during the preceding 90 days." If
this supervisory visit does not occur and isn't properly
documented, then there has been no confirmation that the aide was
present in the home during the 90 day period and provided
services. Without this required confirmation, the services
allegedly rendered during the 90 day period have not been properly
verified and may not be able to be bill to Medicaid.
Click here to learn more about Reporting Medicaid
and Medicare Fraud.
If you have discovered evidence of government fraud,
contact an experienced False Claims Act attorney before blowing the
whistle. You may be entitled to a substantial reward and the legal
protections afforded to whistleblowers under state and federal
laws. The attorneys of Berger & Montague are nationally
recognized experts in Whistleblower/Qui Tam actions with over a
decade of experience pursuing these complex fraud cases. For more
information or to schedule your confidential consultation, use the
form on this page or call us at 1-800-424-6690.
For further reading:
Our Law Firm's Approach to False Claims and Whistleblower
Tam Litigation Statistics and Trends
Seeking Qui Tam
Does a Qui Tam Relator Need to Identify Specific False Claims
Submitted to the Government?
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