QAPI Perspective
Policy/Procedure: Policies and procedures need to be up-to-date and meet current guidelines.
Implementation: Educate all staff at orientation, and periodically, regarding resident rights. Communicate with staff, families, and residents to ensure care received is appropriate for the diagnosis.
Audit: Periodically perform internal and external audits including checking the OIG and other exclusion lists.
An Ocean County, New Jersey woman admitted defrauding New Jersey state health benefits programs and other insurers by submitting fraudulent claims for medically unnecessary prescriptions. The woman, 36, of Cedar Run, New Jersey,pleaded guilty to information charging her with conspiracy to commit healthcare fraud. From January 2015 through February 2016, she served as a recruiter in the conspiracy and persuaded individuals in New Jersey to obtain very expensive and medically unnecessary compounded medications from an out-of-state pharmacy,identified in the information as the “Compounding Pharmacy.” The conspirators learned that certain compound medication prescriptions — including pain, scar, antifungal, and libido creams, as well as vitamin combinations — were reimbursed for thousands of dollars for a one-month supply.
