Compliance Perspective – False Claims:
The Compliance Officer will review the facility’s policies and procedures regarding billing with the Administrator and the Compliance Committee to determine if the facility is using the Medicare Triple-Check Process to systematically verify the accuracy of data prior to the submission of claims, and if not, to evaluate the advisability of putting the process in place. The purpose of the process is to audit claims internally before submitting them with the goal of reducing the facility’s audit risks and to improve cash flow affected by overpayments and under submitted legitimate claims. Designated Staff will be educated and trained in the Triple-Check Process. A compliance audit will be developed and implemented to determine the effectiveness and to ensure that the process is functioning as intended. In addition to the Triple-Check Process, the RNAC nurse and the designated Therapy representative should verify daily whether the needs of all residents receiving therapy are appropriate for the service and the time spent. The Compliance Officer should request that a compliance audit be conducted to ensure that this daily evaluation of the residents’ therapy is occurring.
Nine nursing homes with locations in both Alabama and Florida and two affiliated rehabilitation consulting companies have reached an agreement to pay $10 million to resolve the government’s allegations of False Claims Violation
s. The allegations assert that the defendants submitted or caused the submission of false claims to Medicare for medically unnecessary rehabilitation therapy services.
Medicare reimburses skilled nursing facilities based on a patient’s Resource Utilization Group (RUG) level, which is supposed to be determined by the amount of skilled rehabilitation therapy required by the patient. The United States alleged that between October 2009 and December 2013, the rehabilitation consultants and the nine skilled nursing facilities’ corporate policies and practices encouraged the provision of medically unreasonable and unnecessary therapy without regard for patients’ individual clinical needs. The companies’ actions resulted in the submission of false claims based on inflated RUG levels.
The allegations resolved by this settlement arose from a whistle blower lawsuit filed under the False Claims Act by three former employees of one of the skilled nursing facilities.
