A Pennsylvania nursing home will pay $819,640 to settle claims that it provided medically unnecessary rehabilitation therapy to residents to maximize revenue, and without prioritizing clinical needs. The settlement resolves allegations in a whistleblower complaint filed under the qui tam provisions of the False Claims Act.
The whistleblower, a physical therapist assistant who provided physical therapy services at the facility through his employment with a contracted therapy provider, generally alleged that the nursing home overbilled federal healthcare programs such as Medicare for therapy services. He alleged that the facility: (a) overbilled federal healthcare programs such as Medicare for therapy services provided; (b) billed for services not provided; (c) billed for unreasonable, unnecessary, and sometimes harmful therapy; and (d) allowed the therapy provider to manipulate clinical services to maximize billing.
During the relevant time period, Medicare Part A paid for services rendered to a beneficiary in a skilled nursing facility at a daily rate based, in part, on a Resource Utilization Group (RUG) to which the beneficiary is assigned. Each distinct RUG was intended to reflect the anticipated costs associated with providing nursing and rehabilitation services to beneficiaries with similar characteristics or resource needs. The highest reimbursement level was Ultra High or RU. The resolution is based on claims that the nursing home caused the submission of false claims for Ultra High RUG therapy levels despite evidence that the RU level of therapy was not reasonable or necessary for the respective patients.
Issue:
All skilled services provided should be reasonable and necessary for the specific person. Determination of skilled services should be individualized for each resident, and a trained professional should perform the evaluation to determine if the resident needs skilled services and meets requirements. Submitting claims to Medicare that do not qualify for skilled care, or billing at a level of services that is beyond a person’s need or physical tolerance, can result in false claim allegations. Ensure that staff are aware that submitting a claim for unnecessary skilled services or upcoding for the purpose of financial gain can result in charges of false claims, fines, and other sanctions.
Discussion Points:
- Review your policies and procedures on determining if skilled rehabilitation services are reasonable and necessary. Update as needed.
- Train appropriate staff on how to determine each resident’s level of care and if services provided are reasonable and necessary. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically audit to ensure that skilled rehabilitation services are being provided to residents as documented, and when provided are reasonable and necessary. Also, periodically perform audits to ensure staff are aware of potential compliance and ethics concerns and understand their responsibility to report any potential violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
