Patients in nursing homes and skilled nursing facilities are among the most vulnerable members of our society. Unfortunately, these facilities often take advantage of their patients’ difficult circumstances to submit fraudulent bills to Medicare.
Nursing home Medicare fraud involves dishonest practices, such as billing Medicare for non-existent or unnecessary services in nursing homes. As individuals committed to justice and patient welfare, whistleblowers can be instrumental in exposing these fraudulent practices.
The False Claims Act plays a significant role in holding culprits accountable and compensating the federal government for losses incurred through deceitful claims.
This article provides an overview of nursing home Medicare fraud, ways to spot it, and how the False Claims Act empowers whistleblowers to take action.
Get in touch today for a free confidential assessment of whether you might have a potential nursing home fraud lawsuit that could result in a whistleblower award:
- Contact us for a free confidential consultation
- Call us at 617-823-3217
Understanding Nursing Home Medicare Fraud
There are several ways in which nursing home Medicare fraud can occur:
- Billing for Medically Unnecessary Services: This involves charging Medicare for services that are not necessary for the patient’s health. Fraudulently obtaining funds from this program deprives other Medicare beneficiaries of the crucial assistance they need.
- Billing for Non-Existent Services: In some instances, nursing homes might bill Medicare for services that were never provided to the patients.
- Overutilization of Services and Supplies: This happens when a nursing home unnecessarily administers tests or uses excessive medical supplies and then bills Medicare for these services and products.
- Upcoding: This type of medical billing fraud inflates bills by using billing codes that indicate the patient needed more expensive services than were actually provided.
Understanding and recognizing these fraudulent practices is pivotal in the fight against nursing home Medicare fraud.
The Role of Skilled Nursing Services in Medicare Fraud
Skilled nursing services refer to specialized medical care provided by trained professionals such as registered nurses, physical therapists, or occupational therapists. These services are essential for patients who require medical attention beyond basic nursing care.
However, in the context of Medicare fraud, skilled nursing services can be manipulated in various ways, such as:
- Falsifying Needs: A skilled nursing facility might deceitfully assert that a patient requires skilled care, thereby billing Medicare for unnecessary services.
- Upcoding Services: Similar to other forms of healthcare fraud, skilled nursing facilities might use codes indicating more intensive services were provided than what was actually rendered.
- Inadequate Staffing: Some facilities may fail to maintain adequate staffing levels, which can contribute to the delivery of substandard care to nursing home patients.
By understanding how skilled nursing services can be exploited, one can remain vigilant and help combat Medicare fraud.
The False Claims Act: An Important Tool Against Fraud
The False Claims Act (FCA) is a federal law that combats fraud against government programs, including Medicare. Under the FCA, individuals or entities that knowingly submit false claims to the government can face severe penalties and be required to pay damages.
The federal government recovered over $2.2 billion in judgments and settlements under the False Claims Act in the 2022 fiscal year, and cases relating to health care fraud represented a significant majority of those recovered funds.
For nursing home Medicare fraud cases, the False Claims Act serves as a strong deterrent and an effective tool for holding fraudulent healthcare providers accountable, ensuring the protection of taxpayer funds, and maintaining the integrity of crucial healthcare programs like Medicare and Medicaid.
The Power of Whistleblowers and Whistleblower Lawsuits
One of the powerful features of the FCA is its qui tam provision, which allows private citizens, often called “qui tam relators” or whistleblowers, to file lawsuits on behalf of the government against those involved in fraudulent activities. If the government brings a successful enforcement action resulting in a settlement or judgment, the whistleblower may receive a portion of the recovered amount as a reward.
Successful whistleblower lawsuits can result in substantial recoveries for the government, and the corresponding whistleblower awards can likewise be substantial. (For instance, in the RehabCare case discussed below, the whistleblower rewards totaled nearly $24 million).
Additionally, the False Claims Act protects whistleblowers against retaliation, encouraging more individuals to come forward without fear of repercussions. A skilled nursing home fraud lawyer can be a crucial resource for whistleblowers, ensuring the benefit of the protections laid out in the FCA as well as advocating for awards that fairly compensate their contributions to fighting fraud.
Examples of Nursing Home Fraud Cases
At Jeff Newman Law, we have a long track record of bringing successful whistleblower cases against nursing homes and their rehabilitation therapy providers who fraudulently bill Medicare for services that were either medically unnecessary or never provided at all.
Examples of representative cases the healthcare fraud whistleblower lawyers at Jeff Newman Law have handled include:
- A $125 million settlement to resolve allegations that RehabCare, then the nation’s largest provider of rehabilitation services in nursing homes, engaged in a variety of schemes to bill for therapy that was not reasonable and necessary, and violated the False Claims Act by causing its nursing home customers to submit false claims to Medicare for the therapy;
- A $10 million settlement to resolve allegations that Saber Healthcare, a nursing home chain, knowingly caused certain of its skilled nursing facilities to submit false claims to Medicare for rehabilitation therapy services that were not reasonable, necessary, or skilled;
- A $4 million settlement to resolve allegations that Encore Rehabilitation had policies and practices at three Michigan skilled nursing facilities that resulted in the provision of unreasonable, unnecessary, or unskilled rehabilitation therapy or the recording of therapy minutes as individual therapy when concurrent (or group therapy) was actually provided; and
- A $3.9 million settlement to resolve allegations that nursing home chain Wingate Healthcare submitted false claims to Medicare for rehabilitation therapy that was not reasonable and necessary.
Our firm has extensive experience working alongside government actors as they build cases that lead to successful enforcement actions, such as the U.S. Department of Health and Human Services, U.S. Attorney’s offices, and their various law enforcement partners.
Identifying Potential Fraud: Red Flags
Detecting nursing home Medicare fraud requires a keen eye for certain red flags that may indicate dishonest practices. Here are some common signs to watch out for:
- Discrepancies in Billing: If you notice discrepancies between the services billed to Medicare and the services actually received by the patient, it could indicate fraudulent billing.
- Excessive Services: A sudden increase in the frequency of services or tests that don’t align with the patient’s medical needs may indicate unnecessary billing.
- Patient Complaints: If patients or their families voice concerns regarding unnecessary treatments or tests, take these complaints seriously, as they could indicate Medicare fraud.
Contact an experienced whistleblower lawyer today
Nursing home Medicare fraud is a grave issue that drains government resources and jeopardizes the well-being of vulnerable patients.
By understanding the various aspects of nursing home Medicare fraud, whistleblowers possess the power to effect change.
At Jeff Newman Law, we specialize in representing whistleblowers in nursing home fraud cases, and we have a long track record of recovering multi-million dollar settlements on behalf of our whistleblower clients.
Get in touch today for a free confidential assessment of whether you might have a potential nursing home Medicare fraud lawsuit that could result in a whistleblower award:
- Contact us for a free confidential consultation
- Call us at (617) 823-3217