Nursing Homes in the U.S. Overcharging Medicare

Medicare fraud lawyers at Pintas & Mullins Law Firm note that Medicare fraud and abuse continue to threaten our nation’s healthcare system. A federal report recently revealed that a considerable number of nursing homes overbill Medicare every year for supposed skilled services, thereby increasing the program’s annual expenses by $1.5 billion.

The federal report is part of a year-long project by the Health and Human Services Department (HHS) to control expenses at the 15,000 nursing homes nationwide that offer skilled nursing, towards which the government spent approximately $32.2 billion during the 2012 fiscal year.

Skilled nursing facilities provide physical, speech and occupational therapy, in addition to assistance with eating, bathing and other daily activities. Wrong information was found in about a quarter of the medical bills from those facilities scrutinized in the report. Most of the false claims involved supposed up-coding, which means the care provider presented bills to Medicare reporting more vigorous services than those that were actually provided. There were also instances where nursing homes gave unnecessary treatments.

Officials said that there was a patient under hospice care who did not want physical therapy but was still given the treatment. Medicare was billed for the treatment. Several nursing homes were billing for treatments that the patient didn’t require or that the care homes didn’t deliver.

The federal report findings arrived at a time when President Obama and legislators are struggling to find a way to halt the increasing expenses associated with entitlement programs. Statistics from the impartial Congressional Budget Office revealed that last year, 13.5% of federal spending was for Medicare. It appears that the program would take up a greater proportion of federal expenses over the next 10 years.

The Obama administration claims that reducing abuse, waste and fraud in Medicare is a key aspect of decreasing the program’s spending. By all estimates, at least 30 percent of medical spending is needless, said a Dartmouth medical professor.

A Medicare spokesman explained that the agency modified its payments to nursing homes to avoid such abuses. The report recommended that the government modify the methods utilized to identify the degree of treatment required, reinforce checks on facilities which billed for unnecessary costs, among other things, and increase assessments of claims from nursing homes.

Based on the combination of services that were provided to a skilled-nursing home, Medicare spendings were anywhere between $214 and $623 for a patient, per day in 2009, the year in which the report was based.

For the report, the federal inspectors concentrated on a randomly chosen set of 499 claims from 245 nursing facilities located in different parts of the U.S. The OIG (Office of Inspector General) provided a name for its overall assessment of the issue – Operation Vacuum Cleaner.

Moving from Medicare fraud to Medicaid fraud, a recent United States Department of Justice release revealed that a former LPN (Licensed Practical Nurse) in Illinois was sentenced by a federal court for accountability in the filing of false claims for fake prescriptions with Medicaid. Earlier this year, the woman pleaded guilty to the charge of healthcare fraud.

While the woman was working at an Illinois nursing home, she requested false prescriptions from the pharmacy for Hydrocodone in such a way that it appeared the drug was for the nursing home residents. However, she would use the drugs for her own consumption. She would steal complete cards of the drug that were meant for residents. She also diverted the Hydrocodone for many nursing home residents for her personal use. As a result, at least 11 false claims for fake prescriptions were filed with the Illinois Medicaid program.

The federal court sentenced the woman to a two-year probation term, imposed a $25 fine on her, and demanded that she pay $101 compensation and $100 for special evaluation.

If you suspect that a company or individual is involved in Medicare/Medicaid fraud, inform a Qui Tam attorney immediately. If your suspicions are correct, you may be entitled to significant compensation.

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