The United States and the State of California have reached a $7,084,000 civil settlement with a California-based nursing home chain and two corporate executives. The allegations involve knowingly submitting false Medicare Part A claims for nursing home residents. Under the settlement, the defendants will pay $6,841,727 to the United States and $242,273 to the State of California, plus interest.
During the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) waived the requirement that a person must have had a hospital stay of at least three days before Medicare Part A would cover skilled care in a nursing home. This allowed residents to move directly into a skilled nursing facility (SNF) for care. If the person already lived in a SNF, the person could remain there and receive that care. The SNF could then submit Medicare Part A claims on their behalf. These waivers expired in May 2023.
In March 2020, the nursing home company’s leadership personnel incorrectly assumed that many long-term residents required skilled care due to the possibility of COVID-19 exposure. They submitted Medicare Part A claims for residents who had been near COVID-positive individuals, aiming to receive higher payments than standard nursing home claims. These claims were often false and fraudulent, as they represented that residents needed skilled care when, in fact, they did not. Typically, the services that they provided for these residents consisted of frequent vital-sign checks.
Generally, residents without COVID-19 symptoms or other acute illnesses do not require skilled care based solely on exposure to a COVID-positive person. Frequent vital-sign checks for residents without acute illnesses or injuries does not meet the threshold for skilled care.
Compliance Perspective
Issue
If a person who has Medicare Part A stays in a hospital for three days or longer and still needs skilled care, the person can move into a nursing home that qualifies as a SNF to receive that care, and the nursing home can submit Medicare Part A claims on behalf of the person to get paid for providing that care, for up to 100 days. Generally, nursing homes can get paid substantially more money on Medicare Part A claims than standard nursing home claims, and Medicare does not cover standard nursing home care. The Code of Federal Regulations and the Medicare Benefit Policy Manual provide examples of when observation and assessment constitute skilled care, and they largely involve personalized monitoring following actual, severe illnesses or injuries such as heart attacks, hip surgeries, and pneumonia, not vital-sign checks based on possible illnesses or injuries. In certain circumstances, the Secretary of HHS, using section 1135 of the Social Security Act (SSA), can temporarily modify or waive certain Medicare, Medicaid, CHIP, or HIPAA requirements, called 1135 waivers. All facilities that participate and receive federal and/or state funds from Medicare or Medicaid must adhere to the rules of participation.
Discussion Points
- Review policies and procedures for preventing and reporting false claims and suspicious billing practices. Update your policies and procedures as needed.
- Train staff on what constitutes skilled care and how to prevent false claims. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of their responsibility to identify compliance and ethics concerns and to promptly report violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Perform Triple Checks for all Medicare Part A claims prior to submission to ensure that medical necessity is supported by appropriate documentation, and that services meet skilled care requirements.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
