Insurance Fraud on the Home (Care) Front The Case of the Irresistible Fresh Strawberries
By Shirley Eileen Fitzgerald, RN
Widowed the summer before, "Mrs. Douglas" found herself living alone and missing her annual
garden of fresh fruits and vegetables. She was overjoyed when her daughter-in-Law arrived
to take her to the doctor's office one sunny afternoon in June with three boxes of the most
luscious strawberries Mrs. Douglas had ever seen.
The doctor's visit was rather routine for
Mrs. Douglas: Blood Pressure Check, Cardiac Rhythm Strip, Weight, Temperature, Pulse,
Respirations. "Dr. Samuels" repeated his litany about Mrs. Douglas needing someone to
check in on her. She was only 62, but caring for her ill husband the past 4 years had
taken a serious toll on her stamina. Besides, he reasoned, since she had private medical
insurance that covered home care nursing visits, perhaps she would at least consider
having a nurse drop by a couple of times a month to check her blood pressure and make
sure she was remembering to take her medications. He renewed her prescriptions.
She knew her daughter-in-law was in a hurry, but they stopped by the pharmacy to pick up the refills anyway.
The thought of fresh strawberries waiting for her brightened her return home. They were
wonderful and she ate every one before they could have a chance to spoil.
At first she thought it must have been the lighting, or maybe something reflecting off her
glasses. As she stood in front of the mirror the next morning Mrs. Douglas noticed strangely
reddened patches of skin on her arms and abdomen. She called Dr. Samuels. He was as patient
as ever, but explained that he really couldn't make a diagnosis over the phone. Since Mrs.
Douglas was without transportation that morning this seemed an impossible obstacle, but perhaps she would
consider letting him try sending out a home care nurse. Mrs. Douglas reluctantly agreed.
The home health nurse, "Sandra," arrived just a few hours later. Mrs. Douglas was so happy to
have the company that she almost forgot about the rash that had brought Sandra to her home
in the first place. Sandra completed her physical assessment and called Dr. Samuels for
orders. Sandra requested that Dr. Samuels order some type of antifungal ointment and
suggested that she could come by twice a day to check on Mrs. Douglas and apply the
ointment for her. Mrs. Douglas liked Sandra and this plan seemed agreeable to all involved.
It wasn't until Sandra's second week of twice daily visits on an afternoon when her
daughter-in-law had dropped by that Mrs. Douglas remembered to tell Sandra about the
wonderful strawberries. Sandra had asked about allergies to medications in her initial
patient physical assessment, but had completely overlooked the possibility of a food
allergy. When Sandra got back to the office, she made a note in Mrs. Douglas' chart
regarding the strawberries, but her message never got to Dr. Samuels.
By the third week, the rash had cleared in the original areas, but had now "spread" to
Mrs. Douglas' legs and buttocks. Sandra continued her twice daily visits to apply the antifungal
ointment, but reminded Mrs. Douglas that she would be off the following weekend and
another nurse would be by to visit instead. By now Mrs. Douglas was looking forward
to Sandra's twice daily visits. Sandra always listened to Mrs. Douglas' complaints
and she was so understanding.
At the end of the fourth week, Mrs. Douglas met Sandra's relief nurse, Linda. Linda
was a lot like Sandra, understanding and caring, but she questioned so many things.
When was it that Mrs. Douglas had eaten the strawberries that were thought to have
caused this rash? Where was the rash before it reappeared in on her legs and buttocks?
Had her doctor changed any of her medications recently? When was the last time she had
seen her doctor? Had her Doctor ever actually seen this rash? Did she have any
difficulty applying the ointment by herself? Had she ever had a rash like this in the
past? Was there a history of diabetes in her family?
Linda made the twice daily visits over the weekend, but by the time she went into the
office to report off on Monday she was beginning to seriously question the treatments
for Mrs. Douglas. This wasn't the first case in which she had suspected Sandra of
extending visits unnecessarily. She knew the number of homecare patients had declined
over the past four weeks and that Sandra was paid per visit.
Certainly a rash from
eating strawberries should have cleared in less than a week. And if it wasn't from
eating strawberries, Linda reasoned that the antifungal ointment might simply be
masking some other more serious health problem such as diabetes (which might manifest
with skin rashes due to the excretion of sugar to the skin on diabetics.) Unfortunately
Sandra and the Home Care Agency Administrator both chose to ignore Linda's concerns.
Linda came to me for advice.
Linda's physical assessment and reasoning were excellent. Mrs. Douglas had been receiving
two skilled nursing visits each day to do something (apply ointment) that she was physically
capable of doing herself. Her rash should have cleared within a week and when it failed to
clear, reappearing elsewhere instead, the doctor should have been notified personally.
Sandra had a duty as a patient advocate to follow-up on these things and arrange for a
doctor's office visit when the rash did not clear. Sandra was obviously receiving
substantial financial benefit from twice daily visits as was the home health agency involved.
I encouraged Linda to first contact Dr. Samuels with her patient care concerns and then
report her observations directly to the insurance company. She would also need to find
another more ethical home health agency if she wished to continue in this field of nursing.
Mrs. Douglas was not guilty of defrauding her insurance company. She was simply lonely
and had placed her trust in those who promised to help her.
Dr. Samuels was not negligent, nor guilty of insurance fraud. He simply trusted a home
health agency to act in a competent, professional manner. He acted appropriately given
the reports he received, but he was not told about the strawberries and he didn't
realize when he renewed the antifungal ointment prescription that it was not a completely
different rash he was treating.
Sandra was an "experienced" home health nurse. She had survived many slow periods with
the agency when the patient population had declined and visits were scarce. Sadly for
her patients, including Mrs. Douglas, what Sandra had learned from her "experience" was
not in the realm of ethics or physical assessment. A simple review of Mrs. Douglas' home
health chart would show that more than 75% of the visits made were unnecessary and that
Mrs. Douglas should have been taken to Doctor Samuels immediately for further evaluation
when her rash did not clear completely in the first week. In this case, Sandra may have
actually masked symptoms of diabetes with the continued use of antifungal ointment without
further diagnostic studies.
Case Management was also ineffective in Mrs. Douglas' case as Sandra was operating in a
dual capacity. Sandra was not only the visiting nurse, but also the agency's Supervising
Nurse "substantiating the need for additional twice daily visits" on a weekly basis.
If you have any reason to suspect fraud in home health care; a wound that does not heal;
an infection or rash that does not resolve; recurrent reports of unobserved falls;
investigate. Review the nurses' notes with particular attention to descriptions of wounds,
sizes, healing and documented ability of patient to perform self care. Compare that
information with any notes made by the attending physician prior to discharge to home health.
And finally, if things are still suspicious and yet inconclusive, consider requesting a
change of home health agency on the case...it might prove very enlightening.
This article was published in the John Cooke Insurance Fraud Newsletter.