Nursing Homes Abuse Blog - By Jonathan Rosenfeld

In a settlement agreement with the U.S. Attorney, the operator of 18 nursing homes in Tennessee and Mississippi has agreed to reimburse the government $ 2 million related to allegations of fraudulent billing practices at its facilities. Further, according to the terms of the settlement, the nursing home will implement an internal fraud-monitoring program and will train its employees on compliance with Medicare rules.

The Medicare fraud settlement was achieved after an operations manager confronted his employer, Vanguard Healthcare about its illegal billing practices at skilled nursing facilities that it owned.  Soon after the charges were made, the company turned around and fired the manager. 

Still concerned about the illegal practices, the ex-employee initiated a lawsuit against Vanguard under provisions of the False Claims Act.  As in other healthcare fraud lawsuits, soon after the individual’s claims were substantiated--- the federal government joined in the suit. In particular, the suit focused on Vanguard’s alleged double billing of services and submitting fraudulent Medicare claims for patients who were not eligible for the program. 

Sadly, as some nursing homes see their budgets get cut, some operators have looked towards Medicare or Medicaid fraud.  In Tennessee alone, federal prosecutors have recovered more than $100 from healthcare facilities that have illegally billed the government for services that were never actually provided or provided by staff not qualified to provide the services.

In addition to reimbursing tax-payer dollars, The False Claims Act also allows the individual who initiates the case (frequently referred to as the Whistleblower) to share in a percentage of the recovery from the illegal enterprise.  Depending on the circumstances, the whistleblower may recover between 10 to 30 percent of the gross recovery.

Related:

Brentwood-based Vanguard to pay $2 million in whistleblower fraud lawsuit, Tennessean.com November 8, 2011

Home Healthcare Fraud Results In Groundbreaking False Claims Act Settlement

False Claims Act Lawsuit Seeks Damages From Nursing Home That Provided Inadequate Care

Nursing Home Bookkeeper Admits To Stealing Money From Facility

The Kentucky nursing home at the heart of a recently filed False Claims Act lawsuit, based upon billing patients for 'worthless services' has apparently faced similar claims brought by patients' families in a civil setting.  

It seems like the Feds maybe a little late to the party?

As reported by Cincinnati.com, Carespring Health Care Management, the parent company of eight nursing homes in Ohio and Kentucky, has been called out for providing poor care to patients in the past. 

According to court records, two out-of-court settlements were made between a Kentucky branch of the nursing home and families of patients from the facilities who filed lawsuits following their injures to their family members during admission to the facilities.  

Further, Carespring's inadequate care had been documented by CMS (Medicare), with with 7 of 8 facilities receiving poor ratings for staffing based upon the time nurses spent caring for each patient.  Similarly, three of the Carespring facilities received just one out of five stars as their overall rating-- a clear indicator of sub-par care.

As the False Claims Act lawsuit moves forward against Carespring, it will be interesting to see if the recently lawsuit by the government is enough of a motivating factor to improve care at their facilities.  By the look of the facilities past track record, it doesn't look like there was much motivation to give patients quality care.

The False Claim Act lawsuit, filed by federal prosecutors, seeks to recover $16 million from the nursing home and its individual owners for providing worthless care to patients--- yet seeking full reimbursement from Medicare and Medicaid.

Related Nursing Homes Abuse Blog Entries:

False Claims Act Lawsuit Seeks Damages From Nursing Home That Provided Inadequate Care

When The Going Gets Tough, Some Nursing Homes Turn To Medicare & Medicaid Fraud

U.S. v. Villaspring Health Center, et al. (pdf)

American Senior Communities has agreed to pay $376,432 under the terms of a settlement reached with Indiana Attorney General Greg Zoeller after it was discovered the company was engaging in Medicaid fraud. 

The alleged fraud involved American Senior Communities submitting claims to Medicaid (a state program) on behalf of seven employees who were ineligible to participate in the Medicaid program due to their criminal histories.  Federal law prohibits any health care providers from participating in the Medicaid or Medicare programs.

In addition to the significant fine, the company has also agreed to implement procedures to prevent these errors from occurring in the future.

Healthcare Fraud

By some accounts, fraud in the Medicare and Medicaid programs costs tax-payers a whopping $6 Billion every year!  Obviously, the significant significant impact of healthcare fraud on our society can not be minimized.  Fortunately, the government has created provisions of the False Claims Act (31 U.S.C. Section 3729) which provide a financial incentive for healthcare workers to report corporate healthcare fraud.

The False Claims Act empowers health care workers in nursing home or hospital settings to report fraudulent billing practices perpetrated by their corporate employers. In pursuing a claim under the False Claims Act, an employee who witness unlawful acts to bring a lawsuit against the perpetrating company on behalf of the government. The lawsuit is referred to as a Qui Tam action.

As an incentive to pursuing a Qui Tam lawsuit (whistle blower), a healthcare worker may be entitled to a substantial portion of the recovery related to the fraud.  Similar to a plaintiff in a personal injury case, a nursing home worker may be entitled to 20-30% of the proceeds.

Unfortunately, as corporations continue to put their bottom lines ahead of ethical practices, healthcare fraud continues to be a part of some companies customary business practices. 

Common examples of healthcare fraud include that may give rise to a cause of action under the false claims act include:

• Pharmacy Fraud

• Billing for services that were never provided

• Charging for services with a patient who was deceased or no longer a patient in the facility

• Inflating time sheets that do not accurately reflect the time spent with patients

• Using inferior medicine or medical equipment, yet billing the government for the premium services

Related:

If I Work In A Nursing Home Where I Suspect Fraud, Can I File A Qui Tam or Whistleblower Lawsuit?

When The Going Gets Tough, Some Nursing Homes Turn To Medicare & Medicaid Fraud

Nursing Home Bookkeeper Admits To Stealing Money From Facility

State Reaches Settlement With Nursing Home Operator Inside Indiana Business, December 6, 2010

The United States’ population of older adults is increasing rapidly. With this growth, the number of older adults requiring physical therapy is also increasing. There are different concerns when performing physical therapy with older adults as opposed to younger patients. 

Older adults have weaker bones and are more vulnerable to injury, including dangerous falls. Therefore, it is important that there are enough physical therapists who specialize in or are educated in geriatric therapy in order to reduce the risk of injury. 

Many physical therapist (PT) and physical therapist assistant (PTA) programs have made efforts to incorporate geriatrics into existing curricula. However, barriers to the expansion of geriatric clinical internships exist because of lack of funding, lack of qualified faculty, and lack of student interest. It seems obvious that schools need to make additional efforts to improve their geriatric programs because of the growing demand. 

All Medicare-certified nursing home facilities are required to assess each resident’s status and needs, including the medical necessity for physical and occupational therapy. In order to qualify for Medicare coverage, the therapy must be: reasonable, necessary, specific, and effective treatment for the resident’s condition. The Department of Health and Human Services, Office of Inspector General released a report in 1999 on the Cost of Improper Billings to Medicare. 

This report revealed that Medicare reimbursed skilled nursing facilities for almost $1 billion of improperly billed physical and occupational therapy in 1998. The primary reason was because the therapy was not medically necessary or was performed by staff that did not have the appropriate skill for the resident’s medical condition. Medicare also reimbursed skilled nursing facilities almost $331 million for undocumented physical and occupational therapy in 1998. 

These discrepancies in Medicare covered physical therapy are alarming because residents might not be receiving physical therapy that was ordered by their physicians. Some residents’ medical records did not match the time billed to Medicare for therapy. So, either they did not receive the prescribed amount of therapy or their charts had errors, either of which is worrisome.

When a physician prescribes physical therapy for a nursing home resident, that resident should receive the therapy from a staff member with the appropriate skill level; otherwise, who is to say that the resident is receiving the full benefit of the therapy or that the therapy will be safely performed. 

It is important that nursing home staff members ensure that each and every resident’s medical records match physician’s orders and Medicare bills so that residents receive proper treatment and that treatment is recorded. Without such precautions, vulnerable nursing home residents can suffer serious injuries. 

A news report revealed that some nursing home facilities are competing with hospitals and rehabilitation facilities for short-term patients who require postoperative rehabilitation. These nursing homes often offer treatment at lower costs, allowing people to save money. This is because Medicare estimates that a nursing home can rehabilitate a knee or hip replacement patient for far less than a hospital (from 33-50% less cost than a hospital, see chart on right). This is because nursing homes have a lower overhead than hospitals. 

However, some people criticize nursing homes’ lack of expertise when compared to hospitals. Some data shows a decline in the quality of their rehabilitative care (In March 2007, the Medicare Payment Advisory Commission cited data that it said showed a falling quality of rehab care at nursing homes). Some nursing home rehab facilities don’t have the same access to therapy equipment or doctors as hospital rehab facilities. This calls into question how well nursing homes can offer rehabilitative services to these people, many of whom are younger than the typical nursing home resident. As the number of residents requiring rehabilitative services grows, you have to ask whether the quality of care offered by nursing homes can keep up or will your health suffer?

Sources:

American Physical Therapy Association: Liability Awareness
Illinois Physical Therapy Association: Professional Liability/Malpractice Insurance

FindArticles.com: Malpractice by Physical Therapists, Descriptive Analysis of Reports in the National Practitioner Data Bank Public Use Data File, 1991-2004

Department of Health and Human Services: Office of Inspector General: Physical and Occupational Therapy in Nursing Homes Cost of Improper Billings to Medicare

Related Nursing Homes Abuse Blog Entries:

Physical Therapy For Nursing Home Patients

Yes. Under the Federal Civil False Claims Act (31 U.S.C., Section 3729), private citizens act on behalf of the Federal or State Government to bring an action against government contractors or any company who acts fraudulently with government funds. Under the False Claims Act, a qui tam lawsuit entitles individuals employed by the entity guilty of fraud to bring a lawsuit for fraud-related damages against the offending company. 

Fraud Is Rampant In The Nursing Home Industry

Many nursing homes and medical service providers have turned to illegal practices to boost their bottom line.  By some accounts, up to 10% of Medicare charges have some some type of fraud. Examples of fraud-related qui tam cases in the nursing home setting include:

• Ghost billing- billing for patients that do not exist
• Using inferior medicine or medical equipment, yet billing the government for the premium services
• Billing more than once for the same service
• Billing for services not performed
• Offering free items or services in exchange for a Medicare or Medicaid number
• Waiving co-payments routinely
• Someone other than the physician completing the Certificate of Medical Necessity

Qui Tam Lawsuits Can Be Lucrative To Those Who Report Fraud

The government recognizes that fraud in the medical field leads increased costs and inefficiency.  Further, the government realizes that they have the best chance of discovering medical fraud by providing a financial incentive to those who witness illegal acts.

If you uncover a situation where you believe the government is being defrauded, qui tam whistleblowers have the right to recover between 15 and 30 percent of the total amount recovered from the fraud lawsuit.   The damages related to qui tam lawsuit can be substantial as the party initiating the lawsuit can sue for triple the amount of actual fraud damages plus civil penalties ranging between $5,500 to $11,000 per claim. 

For example, if a nursing home charged Medicare $50 per physical therapy sessions for 1,000 sessions, it never provided to residents, the potential damages under a qui tam theory could be $11,150,000 ($50 x 1,000 = $50,000 x 3 = $150,000 + 1,000 x $11,000).  In this case, the whistleblowing employee could be entitled to $3,345,000.

In the year 2003 alone the amount of U.S. recoveries in qui tam cases totaled 7.8 billion, with whistleblowers recovering a total of 1.3 billion.  If you suspect any person, company or entity involved in defrauding the government, you should contact an experienced qui tam lawyer. 

At Rosenfeld Injury Lawyers, not only do we have experience handling qui tam matters, but we have the unique advantage of understanding the inner workings of nursing homes and other medical facilities having litigated many cases against these entities.  We put this experience to work for you.

Lastly, qui tam cases require you to act quickly. In many situations only the first individual to file a claim will have a right to compensation.

Examples Of Qui Tam Related Recoveries:

• $355,000,000 AstraZeneca
• $334,000,000 Amerigroup
• $325,000,000 HealthSouth
• $257,000,000 Bayer
• $155,000,000 Medco Health
• $49,000,000 Pfizer
• $26,000,000 Key West Pharmacy

Qui Tam Web Resources:

FALSE CLAIMS ACT CASES: GOVERNMENT INTERVENTION IN QUI TAM (WHISTLEBLOWER) SUITS

Medicare Fraud

HHS Takes Further Steps to Protect Medicare From Fraudulent Durable Medical Equipment Suppliers