On August 16, 2021, the US Attorney’s Office in Chicago announced that a Chicago nursing facility has agreed to pay $360,000 to resolve civil allegations that it violated the False Claims Act by providing unnecessary and “upcoded” physical, occupational, and speech therapy services to increase Medicare payments.
A consent judgment and settlement agreement resolve allegations that from 2008 to 2016 the Chicago based nursing facility provided medically unnecessary services to Medicare beneficiaries, first through a third-party skilled therapy vendor, and then through its own skilled therapy affiliate. The allegations contend that the Chicago based nursing facility pressured others to meet quotas for the proportion of Medicare Part A beneficiaries utilizing the highest-possible reimbursement level, known as the Resource Utilization Group (RUG) score, in an effort to increase Medicare payments. The Chicago based nursing facility also allegedly claimed payment for therapy services without a physician order and at other times reported that skilled therapy had been provided, when in fact the patients were not participating in therapy or were unable to undergo or benefit from it.
The consent judgment and settlement agreement resolve claims in two civil lawsuits filed in U.S. District Court in Chicago by a former employee of the third party skilled therapy vendor under the qui tam or whistleblower provisions of the False Claims Act. The Act permits private citizens to bring lawsuits on behalf of the United States for false claims, and to share in any recovery. The United States intervened in both lawsuits prior to entry of the consent judgment and settlement agreement.
The settlement and consent judgment with the facility and the facility’s own skilled therapy affiliate were entered Friday in U.S. District Court in Chicago. The United States in 2019 reached a settlement with the therapy company and its owner, requiring them to pay $1.09 million to resolve alleged False Claims Act violations.
The civil allegations are accusations only, and there was no determination of liability as part of the settlement and consent judgement.
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 unintentional. 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 statute violation. Update your policies and procedures if needed.
- Train all staff on the False Claims Act and Anti-Kickback Statute and what can be considered a false claim or kickback. Include information 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 that 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: UNDERSTANDING AND USING THE MEDICARE TRIPLE CHECK PROCESS and WHISTLEBLOWER STATUTES.
