Virginia Practice Pays $2M For False Documentation

A hospital in Virginia agreed to pay $2,378,731.06 for submitting claims to Medicaid that were improperly modified by the request of the practice’s employee.  Here is the press release.  This is a reminder that modifying and changing documentation should not be done for mere payment purposes.   

Physicians can amend, correct, and enter delayed entries in medical records, but there are specific requirements for making such entries.   

1. The date and author of any amendment, correction or delayed entry must be identified. 

1. The changed or addenda information should clearly and permanently be denoted. 

For example, when a clinic note is signed, the author or another party cannot delete or permanently remove any wrong information.  The proper amendment must be made to correct the error properly.  For handwritten notes, a single line drawn through the error, not it was an error with the initial and date, and create an amendment with the correct information with the current date and signature of that entry.  See the Medicare Program Integrity Manual Sections 3.3.2.4 and 3.3.2.5 for proper medical record corrections.