FRAUD/ABUSE

1. Exclusion – According to a 4/29/15 special Investigative Report printed by Reuter, many physicians and other healthcare providers who, because of wrongdoing, have been excluded from participation in Medicare and/or a state Medicaid’s program, continue to operate in and bill to another state Medicaid program without detection. According to the article, Reuters found 1,800 banned providers that were still able to bill elsewhere on a given date in 2014. The problem was originally caused by the CMS data sharing system which has now been replaced with an Excel file that is updated every two weeks. The article also points out that every state has its own Medicaid rules and do not have to exclude a provider banned from Medicare unless the reason for termination falls under the State’s definition of “for cause”. Read more…

FRAUD/ABUSE

1. Long Term Care Rehab Therapy – A federal District Court Judge dismissed a False Claims Act Whistleblower lawsuit against a Georgia nursing home alleging that the nursing home and its rehab therapy provider billed Medicare for services that were medically unnecessary and excessive. The Court agreed that the correct standard to prove that therapy provided in a skilled nursing facility under Medicare Part A was medically unnecessary is whether those services could not be expected to result in “material improvement”. The Court also dismissed the case because the Complainant/Government “had only unsubstantiated allegations of medically unnecessary care, and not allegations of specific false claims or those showing business practices likely to result in false claim submissions.”

Read more…

FRAUD/ABUSE

1. Long Term Care Rehab Therapy – A federal District Court Judge dismissed a False Claims Act Whistleblower lawsuit against a Georgia nursing home alleging that the nursing home and its rehab therapy provider billed Medicare for services that were medically unnecessary and excessive. The Court agreed that the correct standard to prove that therapy provided in a skilled nursing facility under Medicare Part A was medically unnecessary is whether those services could not be expected to result in “material improvement”. The Court also dismissed the case because the Complainant/Government “had only unsubstantiated allegations of medically unnecessary care, and not allegations of specific false claims or those showing business practices likely to result in false claim submissions.”

Read more…

MEDICARE/MEDICAID NEWS &APPEALS OF CMS PENALTIES/REMEDIES

1. MDS Focused Surveys to be expanded nationwide in 2015- In 2014 CMS, in conjunction with 5 volunteer States (MD, PA, VA, IL, and MN) piloted a survey to assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and its relationship to resident care in nursing homes. CMS plant to expand the MDs focused surveys to all States and include a review of nursing home staffing in 2015. Training for the surveys will begin in April 2015.

Read more…

FRAUD/ABUSE

1. Resident Abuse – An employee of Texas nursing home was arrested and accused of beating resident as a result of video taken by hidden camera placed in the room by resident’s family member with permission of facility. Resident’s family member had noticed several “unexplained injuries” and had taken those concerns to the management who agreed to having a hidden camera installed in resident’s room. Subsequent video taken by the hidden camera showed the arrested employee hitting the resident in her face and pulling resident out of the shower by her arm.

Read more…

FRAUD

1. Fraudulent Billing – Long Term Care Podiatric Services – Podiatrist, as sole practitioner and independent contractor for Preferred Podiatry Group, Inc. (PPG) pleads guilty to felony health care fraud for false billing for incision and drainage of abscesses and hematomas on occasions when he only clipped toenails. Podiatrist agreed to judgment of $999,170 representing the amount of reimbursement he received for false claims.

Read more…

FRAUD

1. Hospice: The U.S. Department of Justice has filed a whistle-blower suit against Creekside Hospice II LLC and its holding company alleging that they knowingly submitted false claims for hospice care for patients who were not terminally ill and instructed staff to falsify records, billed for doctors visits that never occurred, and discouraged staff from documenting improvements in patient’s health and from permitting patients and families from revoking their election of hospice. This action was originally brought by two Creekside clinical managers under the whistleblower provisions of the Federal False Claims Act and the Nevada False Claims Act.

Read more…