Physicians are not allowed to alter their patient medical records once a request for medical records has been received.

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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
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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
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be made in the medical records while maintaining their
integrity. Here are the three points to note.
•
•
•
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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