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Altering Medical Record Entries: Fraudulent Behavior and How to Avoid It Altering medical records is a grave offense that can be heavily punished. Physicians are not allowed to alter their patient medical records once a request for medical records has been received. Why do providers make alterations in the records? In many cases, corrections are made to conform to the dates of service requested in the audit. In other instances, information may be added inappropriately to the medical record. Here is a list of activities that are clearly fraudulent behavior with regard to medical records.
Types of Alterations • Adding to an existing record at a later date without any indication that the addendum is a later entry • Omitting important facts • Changing the dates to make it appear that it was written at an earlier date • Adding to another provider’s notes • Rewriting the record • Adding inaccurate information http://www.mosmedicalrecordreview.com/ 18006702809
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How Signs of Tampering Are Identified Attorneys reviewing medical records would be careful to look for signs of tampering, and usually medical record review professionals assisting the attorneys will easily identify these modifications. Some of the signs of tampering include: • • • • • •
Lack of uniformity in handwriting Crowded writing around existing entries Attempts to erase entries Different pens/typewriters used to write one entry Impressions/lack of impressions made by pen/pencil etc on the following pages Uneven typed notation
To avoid the dire consequences that can stem from fraudulent behavior, providers need to be extra cautious about the way they make entries in the medical records. What is rather worrying is that the “fraudulent behavior” may sometimes be inadvertent and result from the provider’s lack of information regarding the right way to make the necessary alterations.
How to Avoid Fraud When Making Necessary Corrections Chapter 4, Section 4.2.1 of CMS’ Program Integrity Manual provides clear directions as to how corrections can http://www.mosmedicalrecordreview.com/ 18006702809
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be made in the medical records while maintaining their integrity. Here are the three points to note. •
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Mark through the original entry with a single line; it is important that the original entry is still readable. Initial the marked-through entry and date the entry. Now enter the corrected or modified information. This corrected entry also has to be initialed and dated so that it is clear when the correction was made. If you are only adding information, specify the date you added the info and initial the entry.
CMS’ Program Integrity Manual stresses that providers are obliged under law to conform to the requirements of the Medicare program. If fraudulent behavior is identified, it may lead to “imposition of restitution, fines and, in some instances, imprisonment. In addition, there is also a range of administrative sanctions (such as exclusion from participation in the program) and civil monetary penalties that may be imposed when facts and circumstances warrant such action." Now you know why fraud of any kind must be avoided when making entries in medical records. Whether intentional or not, falsification of medical records is a serious offense. Follow the guidelines provided by CMS and ensure that your medical records are unambiguous and provide the right information of your patients. Posted by MOS Medical Record Review Company http://www.mosmedicalrecordreview.com/
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