Compliance Perspective – False Claims
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The Compliance Officer should work with the Compliance Committee to develop and implement a system for reconciling the level of therapy provided to residents, the actual therapy needed, and the reimbursement requests submitted. The Compliance Officer should request that staff audit residents receiving therapy to determine if what they are receiving is appropriate for their need and ability and willingness to participate. The Compliance Officer should spend time talking with and developing relationships with therapists and residents to encourage open communication and awareness about the care being provided and received.
A Louisville, Kentucky, based healthcare company that owns and operates approximately 115 skilled nursing facilities, including 7 in middle Tennessee, has agreed to resolve allegations that it violated the False Claims Act by knowingly submitting false claims to Medicare for rehabilitation therapy services that were not reasonable, necessary and skilled, the Department of Justice announced recently. The settlement also resolves allegations that the company submitted forged pre-admission certifications of patient need for skilled nursing to the state of Tennessee’s Medicaid program. Under the settlement agreements, the company has agreed to pay more than $30 million. As part of the resolution, the State of Tennessee will receive a portion of the overall settlement.
The government alleged that the company engaged in various practices that resulted in the submission of claims for unreasonable, unnecessary, and unskilled services to Medicare patients, including: (1) presumptively placing patients in the highest therapy reimbursement level, rather than relying on individualized evaluations to determine the level of care most suitable for each patient’s clinical needs; (2) providing the minimum number of minutes required to bill at a given reimbursement level while discouraging the provision of additional therapy beyond that minimum threshold; and, (3) pressuring therapists and patients to complete the planned minutes of therapy even when patients were sick or declined to participate in therapy.
The settlement resolves allegations filed in a lawsuit by two former therapy employees, in federal court in Nashville, Tennessee. The lawsuit was filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private individuals to sue on behalf of the government for false claims and to share in any recovery. The Act also allows the government to intervene and take over the action, as it did in this case. The two women will receive a portion of the recovered funds.
