A skilled nursing corporation (“corporation”) based in Georgia, which owns and operates skilled nursing facilities (SNFs) across the country, has agreed to pay $11.2 million, plus additional amounts if certain contingencies occur, to resolve allegations that the corporation violated the False Claims Act. The allegations include that the corporation’s SNFs billed Medicare for rehabilitation therapy services that were not reasonable, necessary, or skilled and that the corporation billed Medicare and Medicaid programs for grossly substandard skilled nursing services. The settlement was based on the company’s ability to pay.
In 2015, the government filed a consolidated False Claims Act complaint against the corporation, alleging that between October 2008 and September 2012 it knowingly submitted false claims for rehabilitation therapy services as a result of a systematic effort to increase its Medicare billings. The United States’ complaint alleged that, through corporate-wide policies and practices, the corporation exerted significant pressure on its SNFs to meet unrealistic financial goals, resulting in the provision of medically unreasonable, unnecessary, or unskilled services to Medicare patients. The corporation allegedly set these aggressive, prospective corporate targets for the highest Medicare reimbursement rates without regard for its patients’ actual clinical needs, and then pressured its staff to meet those targets. The corporation also allegedly sought to increase its Medicare payments by delaying the discharge of patients from its facilities, even though the patients were medically ready to be discharged.
This settlement also resolves allegations that between October 2008 and September 2012, the corporation knowingly submitted false claims to Medicaid for coinsurance amounts for rehabilitation therapy services for beneficiaries eligible for both Medicare and Medicaid and for whom the corporation also allegedly submitted or caused the submission of false claims to Medicare for those services.
In addition, this settlement resolves allegations that between January 2008 and December 2018, the corporation knowingly submitted false claims for payment to Medicare and Medicaid for grossly and materially substandard and/or worthless skilled nursing services. The government alleged that some of the nursing services provided by the corporation’s SNFs failed to meet federal standards of care and federal statutory and regulatory requirements, including failing to have sufficient staffing in certain facilities to meet specific residents’ needs. The government also alleged that in certain SNFs, the corporation failed to follow appropriate pressure ulcer and falls protocols, and failed to appropriately administer medications to some of the residents.
In connection with the settlement, the corporation entered into a five-year chain-wide Corporate Integrity Agreement (CIA) with HHS-OIG that requires an independent review organization to annually review patient stays and associated paid claims by Medicare for those stays. In addition, the corporation is required to engage an Independent Monitor to review the quality of resident care. CIAs promote compliance and protect vulnerable nursing home residents.
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act against the skilled nursing corporation.
Compliance Perspective
Issue
It is extremely important that all members of the healthcare team are aware of what may be considered a false claim or a kickback. Ensure that all staff are aware that these violations can occur whether they are intentional or not intentional. Failure to promptly report a false claim or kickback can result in lawsuits, fines, and other sanctions. Additional information is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 1, Compliance and Ethics Program, CP 2.3 General Legal Duties and Antitrust Laws.
Discussion Points
- Review policies and procedures for preventing and reporting a false claim or anti-kickback violation. Update your policies and procedures as needed.
- Train all staff on the False Claims Act and Anti-Kickback Statute and what can be considered a false claim or a kickback. Teach billing staff to monitor for any episodes of dual billing to Medicare and Medicaid for the same services. Ensure that therapy staff only provide the level of care that meets each resident’s specific rehabilitative needs. Include information in all educational sessions on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically audit staff to ensure that they are aware of what should be done if they suspect a false claim or illegal kickback has occurred, whether intentionally or unintentionally. Conduct audits of documentation and billing routinely to prevent and detect errors before they progress to a false claim.
FOR MORE INFORMATION ON THIS TOPIC VIEW:
FRAUD MODULE 3 – MASTERING LEGAL IMPLICATIONS AND ANTITRUST LAWS and UNDERSTANDING AND USING THE MEDICARE TRIPLE CHECK PROCESS.
