For-Profit Nursing Homes Fuel Rise In Fraud And Abuse Charges

The rise of for-profit nursing homes is proving tragic for some of the nation’s most vulnerable people, resulting in a spike in waste, fraud and abuse charges brought by federal authorities, according to a new report.

An investigation of government data and court filings from Bloomberg News reveals horrifying circumstances at these facilities: A 92-year-old lung cancer patient given physical therapy after spitting up blood. An 80-year-old woman who couldn’t support her own head forced into a “standing frame” for over an hour. An unattended 77-year-old patient who choked on her dinner.

The profit motive is having an outsize affect on quality of care, according to Bloomberg, which obtained U.S. government data through Freedom of Information requests. “Thirty per cent of claims sampled from for-profit homes were deemed improper, compared to just 12 percent from non-profits,” according to the article.

Seventy percent of nursing homes were operated on a for-profit basis in 2010, according to an audit by the Medicare Payment Advisory Commission, which counsels Congress. For-profit nursing homes perform better financially: Their profit margins from treating Medicare patients were 21 percent in 2010 compared to 10 percent for non-profit nursing home companies, the commission reported.

Cases filed against the firms by law enforcement and by families of patients who died allege that for-profit nursing home companies pressure facility managers to minimize the number of employees and keep down their hours to save costs. At the same time, these firms push for patients to receive services they may not need, according to the allegations cited by Bloomberg.

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For-Profit Nursing Homes Fuel Rise In Fraud And Abuse Charges

Doctor Sued in Huge Prescription Fraud Case

A psychiatrist who lives in Skokie is being sued for orchestrating what federal authorities are calling the largest prescription fraud case ever in Chicago.

The defendant, Dr. Michael J. Reinstein, received illegal kickbacks from pharmaceutical companies and submitted at least 140,000 false claims to Medicare and Medicaid for antipsychotic medications he prescribed for thousands of mentally ill patients in area nursing homes, according to a civil health care fraud lawsuit filed today.

Reinstein also submitted at least 50,000 claims to Medicare and Medicaid, falsely stating that he provided “pharmacologic management” for his patients at more than 30 area nursing homes and long-term care facilities, the lawsuit alleges.

The lawsuit seeks triple damages under the False Claims Act, plus a civil penalty of $5,500 to $11,000 for each alleged false claim.

“This is the largest civil case alleging prescription medication fraud against an individual ever brought in Chicago,” said Gary S. Shapiro, Acting United States Attorney for the Northern District of Illinois.

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Doc Sued in Huge Prescription Fraud Case

Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009

Nursing homes are overcharging Medicare to the tune of $1.5 billion annually, a federal report asserts.

The report, titled “Inappropriate payments to skilled nursing facilities cost Medicare more than a billion dollars in 2009,” says that SNFS are upcoding bills to Medicare, either by claiming more services than were done or by giving incorrect treatment.

Under particular scrutiny are physical, occupational and speech therapy, as well as activities of daily living assistance.

A Centers for Medicare & Medicaid Services spokesman told the Wall Street Journal the agency recognizes the overbilling and that doing it “at the expense of taxpayers is unacceptable.” The report, dated Friday, was first reported Tuesday.

Other industry officials have said that nursing homes have upcoded Medicare claims to offset steep Medicaid cuts or losses, and that those days may be coming to an end.
The OIG has bequeathed the name “Operation Vacuum Cleaner” for its look at the issue, the Journal reported. The office has suggested, and CMS agreed with, the following recommendations:

• Increase and expand reviews of SNF claims
• Use of the agency’s Fraud Prevention System to identify SNFs that are billing for higher paying RUGs
• Monitor compliance with new therapy assessments
• Change the current method for determining how much therapy is needed to ensure appropriate payments
• Improve the accuracy of MDS items
• Follow up on the SNFs that billed in error.
CMS concurred with all six recommendations.

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OIG Slams SNFs for Overbilling

Read “Inappropriate Payments to Skilled Nursing Facilities Cost Medicare More Than a Billion Dollars in 2009

FL ALF Owner Sentenced for Medicare Fraud

The owner of a Miami-Dade County assisted living facility (ALF) was sentenced today to 15 months in prison for her role in a kickback scheme that funneled ALF patients to fraudulent mental health providers American Therapeutic Corporation (ATC) and Health Care Solutions Network (HCSN), announced U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; Michael B. Steinbach, Acting Special Agent in Charge of the FBI’s Miami Field Office; and Special Agent in Charge Christopher B. Dennis of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Office of Investigations Miami Office.

Alba Serrano, 66, of Miami, was sentenced today by U.S. District Judge Patricia A. Seitz in the Southern District of Florida. In addition to her prison term, Serrano was sentenced to serve three years of supervised release and ordered to pay $258,329 in restitution.

On June 6, 2012, Serrano pleaded guilty in Miami to one count of conspiracy to commit health care fraud.

According to court documents, Serrano was the owner of Elsa’s House, an ALF that she operated for more than two decades in South Miami. Serrano pleaded guilty to sending Medicare beneficiaries who resided at Elsa’s House to both ATC and HCSN for partial hospitalization program (PHP) services, a form of intensive treatment for severe mental illness, in exchange for illegal health care kickbacks. In her plea agreement, Serrano admitted that she referred beneficiaries to both ATC and HCSN in exchange for cash kickbacks, even though she knew that some of the beneficiaries did not suffer from severe mental illness and accepting health care kickbacks was illegal.

According to the plea agreement, Serrano’s participation in the fraud resulted in at least $591,385 in fraudulent billing to the Medicare program.

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Miami Assisted Living Facility Owner Sentenced for Medicare Fraud

Mount Prospect doctor charged in kickback scheme

A Mount Prospect doctor is one of nine defendants charged in a Medicare fraud scheme.

Masood Syed, 53, is facing five years in prison and a $250,000 fine if convicted.

He is accused of accepting nearly $5,000 in kickbacks from the owners of a Skokie home health care agency in exchange for referring Medicare patients, federal prosecutors said.

 

In addition to Syed, those charged include Dr. Emmanuel Nwaokocha of Skokie, two owners of Rosner Home Healthcare, Inc., a former employee of the agency, the operator of a referral agency, an office manager at a doctor’s office and two home health care marketers.

 

Prosecutors allege the kickbacks have been ongoing since 2008.

 

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Mount Prospect doctor charged in kickback scheme