Five individuals and two for-profit skilled nursing facilities (SNFs) in Pennsylvania were indicted on charges of conspiracy to defraud the United States and related healthcare fraud charges. The Superseding Indictment alleges that the CEO and part-owner of the two indicted SNFs, among others, conspired to defraud the United States and commit healthcare fraud. Two schemes are alleged: first, that management-level employees at the two SNFs knowingly provided, or directed others to provide, falsified staffing records to the Pennsylvania Department of Health (DOH) during federally mandated surveys; and second, that the facilities, under the direction of the CEO and two other regional directors, made false statements in resident assessments, also called Minimum Data Set (MDS) assessments, provided to the government to increase Medicare and Medicaid reimbursements.
The CEO and the former director of nursing of SNF 1, as well as other co-conspirators, added the names of nursing staff who were not in the building on the dates listed on records provided to DOH to make it appear as though these nurses were working and providing direct care to residents. The co-defendants allegedly engaged in these acts in whole or in part, to avoid government sanctions, including a denial of payments for new admissions, additional monitoring, the imposition of civil monetary penalties, and other potential penalties.
The Superseding Indictment charges the former administrator of SNF 2 and the current administrator of another facility owned by the CEO with conspiring to defraud the United States by interfering with and obstructing DOH in its ability to conduct valid federally mandated surveys of the care provided to residents. Among other acts, the Superseding Indictment alleges that the administrator and/or other co-conspirators directed administrative and management-level nursing staff and other employees to “clock-in” for shifts not actually worked. In doing so, SNF 2 created falsified timecard documentation provided to DOH that made it appear as though these individuals were providing direct resident care, when in fact they were not in the building and therefore not providing direct resident care.
In addition, from in and around June 2014 to in and around June 2021, the CEO conspired with two regional-level employees and others to commit healthcare fraud. Among other acts, one of the regional supervisors instructed nursing staff who completed MDS assessments at the various facilities she supervised to make changes to residents’ assessments to ensure that those facilities had certain Case Mix Index (CMI) scores associated with higher reimbursement. She and other co-conspirators also instructed staff at the facilities to create false documentation in residents’ MDS assessments to justify changing a resident’s Activities of Daily Living (ADL) score by writing a note stating that the changes were made after “interviewing” nursing staff, when in fact no such interviews were conducted.
The co-defendants and other co-conspirators also conspired to input inaccurate responses to certain resident questionnaires in order to falsely inflate residents’ depression scores. The Superseding Indictment alleges that they directed these changes in the MDS data to increase reimbursement and not to accurately capture residents’ medical conditions or needs.
Issue:
Correct coding of the MDS is crucial to ensure accuracy of quality measures for your facility and accurate billing. Billing Medicare or Medicaid for services that were not provided is fraudulent activity that is often punishable by fines and imprisonment. Ensure that staff understand that claims should be as accurate and complete as possible, medically necessary, and reviewed carefully before submitted to Medicare or Medicaid.
Discussion Points:
- Review your policies and procedures to determine if revisions are needed to ensure accurate coding of the MDS. Revise your policy as needed when updates are published. Also review your policies and procedures for accurate billing that is supported by documentation detailing provision of services. If not already in place, consider adding a policy for a Triple Check Process for all Medicare Part A claims to ensure services provided, supporting documentation, and billing codes match before claims are submitted.
- Train appropriate staff on how to code the MDS accurately and on how your quality measures are formulated. Also train appropriate staff on how to determine each resident’s level of care and if services provided are reasonable and necessary. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit to ensure that coding is accurately completed by all individuals with responsibility for inputting data for the MDS at your facility. Determine that staff completing any sections of the MDS have the most current version of the users’ manual to guide them, and that they are using it. Also periodically perform audits on claims before they are submitted to Medicare and Medicaid to ensure that the services being billed are necessary, accurate, and that there are no inconsistencies. Staff should be aware of compliance and ethics concerns and understand their responsibility to report any violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
