A US Attorney recently announced that a Pennsylvania nursing home chain will pay $15,466,278 to settle Department of Justice (DOJ) claims that it provided medically unnecessary rehabilitation therapy to residents in order to meet revenue goals, instead of for clinical needs. The nursing home chain operates more than 50 facilities throughout Pennsylvania, Ohio, and West Virginia.
The settlement resolves allegations in a whistleblower complaint filed in federal court in the Eastern District of Pennsylvania under the qui tam provisions of the False Claims Act. The complaint alleged that the nursing home chain pressured its rehabilitation therapists to provide services to meet financial targets and maximize revenue, without regard to clinical need, i.e., certain patients suffered from dementia and did not need or want rehabilitation therapy, but therapists were allegedly pressured to provide those services anyway to meet revenue goals.
Additionally, other patients were allegedly terminally ill and receiving hospice care and had no medical need for intensive therapy, but therapists were pressured to treat those patients to meet the same financial goals.
During the investigation, the nursing home chain voluntarily disclosed employing two people who had been excluded from healthcare programs. Consequently, the settlement also covers claims that the nursing home chain received payment for services by these excluded employees.
In addition to the nearly $15.5 million payment, the nursing home company agreed to enter into a chain-wide Corporate Integrity Agreement with the US Department of Health and Human Services Office of Inspector General. Such agreements promote compliance and protect vulnerable nursing home residents.
Compliance Perspective
Pressuring rehabilitation therapists to provide services to residents without regard to their clinical need or refusal of therapy in order to meet revenue goals, and employing persons who have been excluded from Medicare and Medicaid healthcare programs, may result in the submission of false claims and be considered provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points
- Review policies and procedures for accurately billing therapy based on the revised PDPM guidelines from the Centers for Medicare & Medicaid Services, and for screening of employees to identify if any have been excluded from those healthcare programs.
- Train staff to only provide rehabilitation services to those for whom it is clinically indicated and agreed to by the residents. Also, remind employees to report any pressure to provide therapy in order to meet financial goals to their supervisor or through the Hotline.
- Periodically audit to determine that screenings of new hires for exclusion from participation in Medicare and Medicaid programs have been conducted and are periodically repeated.
FOR MORE INFORMATION ON THIS TOPIC: STAYING ON TOP OF EMPLOYEE CHECKS
