Deliberately placing all patients in the highest therapy reimbursement level without regard to their individual care needs, yet only providing the minimum number of minutes of therapy required to obtain reimbursement, is a fraudulent practice and results in the submission of false claims
Compliance Perspective – Reimbursement
Policies/Procedures: The Compliance and Ethics Officer with the Medical Billing Manager will review the policies and procedures involving the Medicare Triple Check Process for submitting claims for reimbursement of therapy services.
Training: The Compliance and Ethics Officer with the Medical Billing Manager will ensure that staff are trained in the Medicare Triple Check Process for internally auditing claims before they are submitted.
Audit: The Compliance and Ethics Officer with the Medical Billing Manager should periodically conduct an audit to ensure that rehab data is appropriate and accurate, that the RUG category from the accepted MDS matches the RUG on the claim, and that the level of service submitted on the UB-04 is appropriate for the resident and supported by accurate documentation.
A recently settled case by the Department of Justice (DOJ) involved a large nursing home company with 115 skilled nursing homes in several states that knowingly submitted false claims to Medicare and to Tennessee’s Medicaid program.
The false claims that were intentionally submitted were for rehabilitation therapy that was not reasonable, necessary, or provided by skilled practitioners. The company also allegedly submitted forged pre-admission certificates on behalf of patients.
The DOJ alleges that instead of performing individual evaluations to determine each patient’s most suitable level of care, all patients were placed in the highest therapy reimbursement level and were provided with the bare minimum number of minutes of therapy needed to obtain reimbursement. Therapist providers were also discouraged from providing any therapy above the minimum requirement for that level. Patients that were too ill or who declined to have physical therapy sessions were pressured along with therapists to complete their planned therapy.
The company was charged with “illegally boosting profits by providing excessive amounts of therapy to patients whether they needed it or not.”
Two former therapy employees filed the original lawsuit under the whistle blower provisions of the False Claims Act.
