CMS to Review the Diagnosis of Schizophrenia and Use of Antipsychotic Medications in Nursing Homes

On January 18, 2023, CMS issued a press release announcing a new action to reduce what CMS termed the improper diagnosis of schizophrenia and the inappropriate use of antipsychotic medications. While both are laudable goals, and no one would support the improper diagnosis of a patient or the inappropriate administration of medication, CMS will determine the accuracy of a diagnosis of schizophrenia by off-site audits, chart reviews. As a health care fraud and audit defense attorney, I have found that these chart reviews are often biased against the provider. I have represented many clients who had their charts audited by Medicare vendors, with the preliminary results never being favorable. Once we were able to see the results and the reasoning, we can rebut the auditor’s determination. Sometimes we may have to go through a couple of reviews before getting a positive result. In one case, based on a chart review, Medicare claimed a client owed around $1.5 million, only to be overturned by an administrative law judge. In another case, the amount claimed to have been fraudulently billed was reduced substantially by the United States attorney. Some nursing homes have a high population of residents suffering from mental diseases and will, of course, have a higher population of patients properly diagnosed with schizophrenia. Yet CMS can use these audits to report inaccurate coding and will downgrade the facility’s Quality Measure rating to one star. Once again, this new action reinforces the need to document thoroughly and accurately. Although time-consuming, I cannot overstate how vital charting is to avoid a recoupment or civil or criminal investigation.