On June 29, 2021, a California skilled nursing facility operator and its entity agreed to pay more than $451,439 to resolve allegations that they violated the False Claims Act. One of the company’s skilled nursing facilities agreed to resolve allegations that an employee knowingly created billing records for services that were not actually provided.
According to the settlement, the healthcare group used false records to bill Medicare, leading it to obtain Medicare reimbursements that were higher than warranted. The government also alleges that the management of the healthcare group learned of the extent of the false billings to Medicare, but it did not conduct an adequate investigation into this conduct, and then failed to submit a refund to Medicare for the full amount management knew had been overbilled or otherwise disclose its false billings to the government.
The Acting U.S. Attorney stated, “Medicare participants who fail to voluntarily disclose fraud, risk significant consequences. As this settlement makes clear, knowingly retaining Medicare funds obtained by fraud is itself a violation of the law, and this office is committed to pursuing enforcement actions to remedy this conduct.”
The settlement with the healthcare group resolves allegations originally brought in a lawsuit filed by a former employee under the whistleblower provisions of the False Claims Act. The Act permits private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery. The whistleblower will receive over $90,000 as her share of the recovery from the healthcare group. The whistleblower’s claims for retaliation and attorneys’ fees are not resolved by this settlement.
A Special Agent of the FBI Sacramento Field Office stated, “The FBI is committed to working with our partners to identify and investigate fraud, especially when it defrauds taxpayer-funded programs. This settlement serves as a warning to Medicare participants to carefully audit and investigate records and billing to ensure their business operations are not in violation of federal law.”
Issue:
Every facility should be conducting a triple check process prior to submitting claims to Medicare or managed care providers for payment. The triple check process, when conducted properly, includes an internal audit that ensures billing accuracy and compliance with regulatory guidelines. Members of the interdisciplinary team (IDT) should be included in the triple check process to provide a check and balance to the entire admissions, billing, and MDS process for Medicare and managed care residents. Should an overpayment be discovered after a claim is submitted, the facility has 60 days after the date on which the overpayment was identified to return the funds. An identified overpayment not reported and repaid timely may be subject to substantial liability under the False Claims Act. The facility’s Compliance and Ethics Officer and Committee should routinely audit to ensure that all overpayments have been reported and repaid within the 60 day rule.
Discussion Points:
- Review your policy and procedure on the Triple Check Process. Update as needed.
- Train all staff who are responsible for your Triple Check Process on the policy and procedure. Document that these trainings occurred and file each signed document in the employee’s individual education file.
- Periodically audit to ensure that the Triple Check process is being conducted per your policy and procedure.
