FRAUD AGAINST MEDICARE

Skilled nursing and hospice care are some of the most expensive areas of healthcare that Medicare and Medicaid cover. In 2016, Medicaid spent nearly $17 billion on hospice services alone and in 2015, Medicare spent $29.8 billion on skilled nursing. The way the government pays skilled nursing and hospice providers leaves the door open for opportunistic providers to commit Medicare fraud. This fraud can occur in a number of ways, but nursing home or hospice fraud often involves providers seeking and receiving more than they have earned from the government.

Because these activities are done in secret and are difficult to detect through government auditing, whistleblowers are essential in reporting and ending fraudulent practices that cost the government money and threaten the effectiveness of patient care.

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SKILLED NURSING FACILITY FRAUD

A skilled nursing facility is a long-term care option for patients who suffered a debilitating injury or illness (like a stroke). After a qualifying stay in the hospital, Medicare beneficiaries frequently need time in a rehabilitation center to recover. A skilled nursing facility provides services like physical therapy, occupational therapy and speech therapy and specialized services for patients dealing with conditions like stroke recovery, Parkinson’s disease care or injury care.

However, a skilled nursing facility is a business and is therefore susceptible to improper practices, illegal deal making and fraud for financial gain. There are a few common types of skilled nursing facility fraud:

  • RUG fraud – A patient in a skilled nursing facility may be placed in the highest resource utilization groups (RUG). This category reimburses the rehab center the most Medicare money. The patient may receive excess or unnecessary care that can be harmful to their recovery. For example, a patient recovering from a stroke may receive unnecessary physical therapy on their knee or ankle that was not in their care plan.
  • Upcoding – Providers may file for reimbursement at a higher level of care than the level actually provided or medically necessary. The procedure codes used are often reimbursed at a higher rate.
  • Unbundling – Skilled nursing facilities can also commit fraud by unbundling the services they provide. In order to increase revenue, providers may code services individually that cost more than the service normally would under a different code.
  • Kickbacks – Kickbacks or bribes are also a prevalent form of skilled nursing facility fraud. This occurs when a provider receives a monetary benefit from referring a patient to a specific care institute. It’s illegal for anyone to provide or offer anything of value in order to have that person give them referrals or generate healthcare business.
  • Medicare Eligibility Requirements – A facility may be billing Medicare for services rendered to patients who do not meet Medicare’s eligibility requirements for the types of services being billed.

These forms of skilled nursing facility fraud are illegal under a number of statutes and regulations; most importantly the False Claims Act (FCA). In such cases, the victims are the residents, receiving improper or unnecessary care so that providers can illegally obtain more funding through healthcare programs like Medicare and Medicaid.

With the help of an attorney, whistleblowers can put a stop to this kind of Medicare fraud. In skilled nursing facility fraud cases, settlements can range between $10 million up to $145 million.

HOSPICE FRAUD

Hospice care is the palliative care provided at the end of a patient’s life. The goal is to ease the suffering of the patient, treating their emotional and physical pain, and to provide some support to the family of the patient. These services can take place in a facility or at the patient’s home. In practice, hospice can be an extremely valuable service for the patient and their family.

However, many hospice providers take advantage of the structure of payment they receive from the government and commit hospice fraud. Facilities committing hospice fraud do so in similar ways that skilled nursing facilities do. They will falsely claim a higher level of care than given or medically necessary, including billing for continuous home care when only routine home care is given or medically necessary. They may even falsely claim that a patient requires continuous home care when the patient actually does not require any hospice care at all.

Hospice providers can also commit fraud in the form of providing kickbacks for referrals.

Providers have paid dearly for committing hospice fraud. In False Claims Act cases, with settlements have reached as high as $76 million.

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WHISTLEBLOWER PROTECTIONS AND BENEFITS

When a skilled nursing facility or hospice care provider commits fraud (whether it be through upcoding, unbundling, kickbacks, or other type of fraud) and receives payment from the government, it has violated FCA. Whistleblowers have the opportunity to stop this type of fraud and receive protection and benefits under the FCA.

When a whistleblower initiates a case under the FCA, they file their complaint under seal, making them highly confidential. It affords whistleblowers statutory protection from employment retaliation if they work for the healthcare provider when they file a complaint alleging an illegal kickback scheme.

The FCA also allow individuals with knowledge of false claims, including skilled nursing facility or hospice fraud, to file suit on behalf of the government to recoup money that has been fraudulently obtained by contractors, including health care providers. The whistleblower is entitled to compensation for bringing a successful FCA case on behalf of the government. This amount can range between 10% and 30% of the total amount recovered depending on the type of information the whistleblower provides. The rewards for both the government and the whistleblower can be significant.

WHISTLEBLOWER ATTORNEYS

Whistleblowers can face severe personal and professional harm as their reward for their stepping forward if they are not backed by an attorney who knows the law and the process of an FCA case. Reporting skilled nursing facility fraud or hospice fraud is extremely complex and requires a close attention to detail and hard work. A serious attorney with extensive knowledge and experience can help.

The attorneys at Price Armstrong have experience in successfully representing whistleblowers in cases of Medicare fraud. If you have information about a kickback scheme, an attorney at Price Armstrong is available for a free consultation regarding your options.

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CONTACT US FOR A FREE CASE EVALUATION

If you have evidence of skilled nursing facility or hospice fraud, contact the attorneys at Price Armstrong. We can help you seek justice and protect your rights throughout the process. Call us today at (205) 208-9588 for a free initial consultation and review of your case. Let us fight for you – call now!