Healthcare Compliance Perspective – False Claims Allegations:
The Compliance Officer should verify with the Compliance Committee that the Policies and Procedures pertaining to submission of claims for reimbursement from federal and state providers are detailed, accurate and verified to avoid improper coding. The MDS Coordinator should be educated to ensure that the RUG levels support the frequency, duration and intensity of services provided. An audit of claims submitted for accuracy in coding should be performed quarterly each year or more often if indicated.
After two former employees of a Kentucky skilled nursing facility filed a lawsuit under the qui tam provision of the False Claims Act, the U.S. Attorney’s Office for the Eastern District of Kentucky and other government agencies opened an investigation. The skilled nursing facility was accused of billing Medicare and the Kentucky Medicaid program for fraudulently inflated skilled nursing services and providing materially substandard care.
Last week, the government announced that a settlement had been reached to resolve the allegations. The settlement payment of $540,000 to be paid to the Commonwealth of Kentucky and to the U.S. involves not only the skilled nursing facility, but also the owner, a large management group and other affiliated entities.
The U.S. alleged that from July 1, 2012 through October 31, 2017 these defendants improperly coded patients for higher amounts of skilled nursing services than they needed or received, resulting in higher payments from Medicare.
The settlement also resolves the government’s allegations that, from July 1, 2012 through April 30, 2015, certain patients at the skilled nursing facility received materially substandard or worthless services.
The management group and its related entities own or operate approximately one-hundred skilled nursing facilities throughout the U.S. The centers owned in Kentucky include the one named in this lawsuit and 20 other centers. In November 2017, the management group, and facilities in Kentucky and New Mexico declared Chapter 11 bankruptcy. The respective bankruptcy courts approved the settlement on June 26, 2018.
