Hotline Report of Altered Time Records and Home Health Visits

Define scope: the 24 suspect visits, the manager’s overtime, and whether others were involved. Preserve evidence: EHR audit trails, emails, texts, time records, badge logs, and scheduling records. Suspend routine deletion and place the manager on administrative leave or restrict access. Engage counsel to direct the investigation and preserve privilege where appropriate. Independence is critical: the COO is conflicted because of the family relationship and should be recused; the compliance officer should report to the board or audit committee chair and counsel. Decide who interviews: counsel or a trained investigator; the compliance officer should not interview the COO’s relative alone. Interview the hotline reporter if willing, then RNs, then the manager; use open-ended questions, document contemporaneously, and avoid promises. Key decisions include whether to self-disclose, whether to repay, whether to terminate, and whether to refer for law enforcement. Those are organization decisions with counsel and the board, not the compliance officer alone. The one-analyst resource gap means engage a forensic auditor or outside coder. Protect the anonymous reporter from retaliation.

The $180,000 is a preliminary estimate; validate each visit against documentation and medical necessity, and calculate the actual overpayment by payer. If Medicare or Medicaid, the 60-day repayment rule may apply once an overpayment is identified; do not wait for the investigation to end if the overpayment is confirmed. Consider the OIG Self-Disclosure Protocol or CMS voluntary disclosure depending on the conduct and payer; ordinary billing errors may be handled by repayment, while false documentation and pressure to upcode suggest potential fraud, and counsel should evaluate disclosure. Employment: remove the manager from patient-care and supervisory duties during the investigation; termination may be appropriate if policy violations are confirmed, but follow HR policy and due process. Do not retaliate against the reporter. Preserve the manager’s records. Board reporting: report the investigation status, the conflict, and the preliminary estimate to the audit committee; the COO should not receive interview notes. Document decisions and rationale.

Corrective action: revise visit documentation and supervision policies; require RN attestation and prohibit managers from editing signed notes without an addendum and audit trail; implement second-level review for all visits documented by the manager’s team for six months; audit 100% of the 24 suspect visits and a random sample of 30 additional visits; train staff on documentation integrity, anti-retaliation, and the hotline; review overtime approval and segregation of duties; monitor EHR audit trails for post-signature edits and managers editing their own or relatives’ records; conduct exit interviews and a culture survey; and report to the board quarterly with metrics including audit error rate, hotline reports, edit patterns, and overtime. Root causes may include production pressure, weak prebill review, and a supervisor with unchecked authority. The plan should assign owners, dates, and evidence. Re-audit in 90 days and report effectiveness. If the investigation confirms fraud, consider referral and disclosure with counsel. Document all actions.