An Indiana provider of skilled nursing and long-term care services has agreed to pay $5,591,044.66 to resolve allegations that it violated the False Claims Act by submitting false claims to the Medicare program.
In 2017, a former employee of a hospice services company doing business with the nursing home provider filed a sealed civil complaint or āwhistleblowerā lawsuit under the False Claims Act in the United States District Court for the Southern District of Indiana. The complaint alleged that the provider had engaged in conduct to defraud the Medicare program. Specifically, the complaint alleged that the provider was charging Medicare directly for various therapy services provided to beneficiaries who had been placed on hospice, when those services should have already been covered by the beneficiariesā Medicare hospice coverage.
Based on the investigation, the estimated loss to the Medicare program was $2,795,522.33. The provider has agreed to pay $5,591,044.66 to the United States.
The resolutions obtained in this matter were the result of a coordinated effort between the US Attorneyās Office for the Southern District of Indiana, the Department of Health and Human Services ā Office of the Inspector General, and the Federal Bureau of Investigation.
Issue:
All submitted claims must be accurate and truthful. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.āÆUnder the civil False Claims Act (FCA), no specific intent to defraud is required. The civil FCA defines āknowingā to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information. Further, the civil FCA contains a whistleblower provision that allows a private individual to file a lawsuit on behalf of the United States and entitles that whistleblower to a percentage of any recoveries.āÆ
Discussion Points:
- Review your policies and procedures for operating an effective compliance and ethics program to ensure that identifying and reporting of false claims is included. Ensure that your policies are reviewed at least annually and updated when new information becomes available.Ā
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Additionally train all staff on what can be considered a false claim, and that Medicare A coverage is all inclusive and charges cannot be unbundled. Business office personnel should confirm that vendors do not bill Medicare directly for items included in the facilityās required Medicare A consolidated billing. Document that these trainings occurred and file the signed document in each employeeās education file.Ā
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any concerns of compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Also ensure that monthly Triple Checks of Medicare Part A claims are conducted prior to submission to prevent false claim submissions.
