There are over 17,000 Medicare and Medicaid-certified nursing homes throughout the United States and many receive most of their income through government programs such as Medicare, Medicaid, and Tricare.  Unfortunately, some of these nursing homes and assisted living facilities are run by corporations, nursing home administrators, therapists, doctors, and nurses that value profits over quality of care and commit Medicare fraud. 

If you are aware of a assisted living facility that is committing Nursing Home Medicare Billing Fraud, feel free to contact Skilled Nursing Facilities SNF Medicare Fraud Whistleblower Lawyer Jason Coomer via e-mail message or our submission form about a potential Nursing Home or Elder Care Medicare Fraud Whistleblower Qui Tam Claim Law Suit. 

Nursing Home Medicare Fraud Whistleblower Lawsuits and Nursing Home Medicaid Fraud Lawsuits (Nursing Home False Billing, Double Billing, Unnecessary Procedures, Upcoding, and Outlier Payment Fraud Lawsuits)

Health care costs in the United States are over $2.3 Trillion each year and are continuing to rise.  Included in these costs are a significant amount of Medicare fraud including nursing home Medicare fraud and assisted living facility Medicare fraud.  Some estimates suggest that health care fraud including Nursing home Medicare fraud is about 10% of the cost of health care.  These numbers are expected to rise as more people become eligible for Medicare and more people move to nursing homes and assisted living facilities.

Because of the growing number of Medicare eligible recipients, more and more people will pay for their health care including nursing homes, hospice, home health care, physical therapy, pharmacies, and medical equipment through Medicare.  The nursing homes and associated health care providers that accept Medicare payments too often find that it is more profitable to use fraudulent billing practices to increase their income from Medicare.  These nursing homes and elder care providers sometimes begin to use systematic Medicare Fraud including upcoding, manipulation of outlier payments to Medicare, illegal kickbacks, charging for unnecessary services, double billing for services, and falsely certifying goods or services that were not provided are all forms of Medicare fraud that cost United States taxpayers billions of dollars each year.   

Skilled Nursing Facility (SNF) Medicare Billing, Elder Care Billing, Nursing Home Revenue, and the Prospective Payment System (PPS)

Most nursing home and elder care costs are taken care of through Medicare, Medicaid, and government programs.  To be able to collect Medicare, Skilled Nursing Facilities have to use the Prospective Payment System and follow government regulations.  Under these regulations, Medicare will pay some nursing home costs for Medicare beneficiaries who require skilled nursing or rehabilitation services. To be covered, the person must receive the services from a Medicare certified skilled nursing home after a qualifying hospital stay. A qualifying hospital stay is the amount of time spent in a hospital just prior to entering a nursing home.  Unfortunately, some Skilled Nursing Facilities are violating the qualified hospital stay requirement.

In the Balanced Budget Act of 1997, Congress mandated that payment for the majority of services provided to beneficiaries in a Medicare covered skilled nursing facilities SNF stay be included in a bundled prospective payment made through the fiscal intermediary (FI)/A/B Medicare Administrative Contractor (MAC) to the skilled nursing facilities SNF. These bundled services have to be billed by the skilled nursing facility to the FI/A/B MAC in a consolidated bill.  This Consolidated Billing in nursing homes was implemented in 1998 and required all skilled nursing facilities (SNFs) and nursing facilities (NFs) to file consolidated billing for Medicare.

Under Consolidated Billing the facility must submit all Medicare claims for the Part B services and supplies that all its Medicare residents receive, except for certain services specifically excluded. Medicare pays the facility, and the facility then reimburses any external providers or suppliers according to contractual arrangements.

There are a number of services that are excluded from skilled nursing facility SNF CB.  These services are outside the PPS bundle, and they remain separately billable to Part B when furnished to an SNF resident by an outside supplier.  However, bills for these excluded services, when furnished to SNF residents, must contain the SNF's Medicare provider number. Services that are categorically excluded from SNF CB are the following:

• Physicians' services furnished to SNF residents.  These services are not subject to CB and, thus, are still billed separately to the Part B carrier.

• • Many physician services include both a professional and a technical component, and the technical component is subject to CB.  The technical component of physician services must be billed to and reimbursed by the SNF.

  • Section 1888(e)(2)(A)(ii) of the Social Security Act specifies that physical, occupational, and speech‑language therapy services are subject to CB, regardless of whether they are furnished by (or under the supervision of) a physician or other health care professional.

• Physician assistants working under a physician's supervision;

• Nurse practitioners and clinical nurse specialists working in collaboration with a physician;

• Certified nurse-midwives;

• Qualified psychologists;

• Certified registered nurse anesthetists;

• Services described in Section 1861(s)(2)(F) of the Social Security Act (i.e., Part B coverage of home dialysis supplies and equipment, self-care home dialysis support services, and institutional dialysis services and supplies);

• Services described in Section 1861(s)(2)(O) of the Social Security Act, i.e., Part B coverage of Epoetin Alfa (EPO, trade name Epogen) for certain dialysis patients.  Note: Darbepoetin Alfa (DPA, trade name Aranesp) is now excluded on the same basis as EPO;

• Hospice care related to a resident's terminal condition;

• An ambulance trip that conveys a beneficiary to the SNF for the initial admission, or from the SNF following a final discharge.

For Medicare beneficiaries in a covered Part A stay, these separately payable services include:

• physician's professional services;

• certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;

• certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary offsite temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services;

• erythropoietin for certain dialysis patients;

• certain chemotherapy drugs;

• certain chemotherapy administration services;

• radioisotope services; and

• customized prosthetic devices.

If you are a nursing home administrator, accountant, benefit coordinator, or other health care professional working with or for a nursing home, it is important to understand proper Medicare billing procedures and to report any significant or systematic Medicare fraud that has occurred.

Nursing Home Medicare Fraud Whistleblower Lawsuits (Hospital Billing for Unnecessary Procedures Qui Tam Claims, Hospital Upcoding Qui Tam Claims, and Hospital Medicare Outlier Payment Fraud Tam Claims)

Too often, our most vulnerable citizens are the ones that are taken advantage of, so special attention is needed to prevent and prosecute these crimes. Each year Medicare and Medicaid spend over $120 billion on long-term care services, including nursing homes.   At the same time, research shows that 11 percent of our seniors report experiencing at least one form of abuse, neglect, or exploitation and health care fraud is estimated to be between 6 and 12 percent of this cost.  

Systematic Nursing Home Medicare Fraud including upcoding, manipulation of outlier payments to Medicare, illegal kickbacks, charging for unnecessary services and procedures, charging for services not provided, double billing, and bill padding, can be difficult to detect and require an inside whisteblower such as a hospital administrator, nurse, therapist, physician's assistant, or doctor to stop the medicare fraud.  Though it can be difficult for the medical professional to blow the whistle on Nursing Home Medicare Fraud and others in their profession, health care professionals that are complicit and allow others to commit nursing home medicare fraud may be subjecting themselves to liability and find that they can be held liable and be at risk for failing to report known nursing home medicare fraud.

Nursing home administrators can be reluctant to report instances of hospital medicare fraud because of potential retribution that can be taken against them including loss of job and damage to career.  However, provisions of the Federal False Claims Act provide protections to whistleblowers and recent amendments to the Federal False Claims Act have been expanded to protect whistleblowers from retribution.

If you are aware of Nursing Home Medicare Fraud, it is important to obtain evidence of the upcoding, manipulation of outlier payments to Medicare, illegal kickbacks, charging for unnecessary services and procedures, charging for services not provided, double billing, bill padding, or other hospital medicare fraud, then contact a medicare fraud lawyer that can assist you with a potential nursing home or elder care medicare fraud qui tam whistleblower lawsuit.

Civil Healthcare Fraud Allegations Settled for $1.4 million (U.S. Attorney for the Northern District of Alabama)

From 2002 until May 2007, the defendants caused false claims for utilization review (“UR”) services to be presented in cost reports to the Medicare Program. Although Medicare guidelines state that only payments made to physicians for their services on UR committees are allowable as cost claims for a skilled nursing facility, the Kings and their respective companies caused certain of their skilled nursing facility clients to present claims which overstated the amount of work performed by physicians. Those false claims increased the Medicare reimbursement to these clients, resulting in losses of over $740,000 to Medicare.

This matter was brought to the attention of the United States through the filing of a qui tam complaint under the False Claims Act. The act authorizes private parties to file suit against those who defraud the United States, and to receive a share of any recovery. The whistleblower was an accountant who worked for a company that prepared cost reports for the skilled nursing facilities, which had been clients of SouthernCare. After conducting its investigation, the United States, on April 30, 2008, intervened in the qui tam action with respect to Bill King, Marie King, King & Associates, and SouthernCare. The United States did not intervene with respect to other parties mentioned in the whistleblower’s complaint. On June 2, 2008, the United States filed its Complaint in Intervention against the Kings and their respective companies.

The settlement agreement filed today in the civil case provides that the United States will pay 19 percent of any amount received to the whistleblower who initiated the qui tam action.  For more information on this case, please go to the following web page.

Relators that Blow the Whistle on Nursing Home Medicare Fraud Can Receive Large Amounts of Compensation for Successful Assisted Living Facility Medicare Fraud Qui Tam Lawsuits (False Claims Act Lawsuits)

The Federal False Claims Act allows citizens to file a suit on behalf of the federal government against anyone who has participated in defrauding the government including any corporation or person that has committed hospital medicare fraud. 

The 1986 Amendment defines a "claim" as:

"...any request or demand which is made to a contractor, grantee, or other recipient if the United States Government provides any portion of the money or property which is requested or demanded, or if the government will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded."

The whistleblower's share of recovery is a maximum of 30 percent and the government's prior knowledge of fraud now does not necessarily bar a whistleblower from collecting lost revenue. If the government took over the lawsuit, the relator can "continue as a party to the action." The defendant is also required to pay for the relator's attorney fees. The whistleblower is also protected from retaliatory actions by his or her employer. As a result or the amendment, qui tam lawsuits increased dramatically.   Though the amendment was first made fore corrupt defense contractors, the amendment has uncovered billions of dollars in health care fraud.

Anyone who defrauds the government out of revenue can be held accountable under the False Claims Act. Common defendants include defense contractors, health care providers, other government contractors & subcontractors, state and local government agencies,  and private universities. Whistleblowers often include current and former employees of the defrauding company, competitors of government contractors and public interest groups.  For more information on Qui Tam Claims and Whistleblower Lawsuits, please go to the following Qui Tam, Whistleblower, and Federal False Claims Act Information Center.