In a March 11, 2022, release by the Northern District of Georgia’s Office of the Department of Justice, it was reported that an investigation determined a Georgia nursing home knowingly submitted claims for unreasonable, unnecessary, and unskilled services for Medicare patients. The Georgia nursing home agreed to pay $400,000 to resolve the allegations. This amount was based on the nursing home’s ability to pay.
It is alleged that between January 2011 and November 2014, the Georgia nursing home submitted claims to Medicare for unreasonable, unnecessary, and unskilled services for rehabilitation therapy. The practices used by the nursing home that resulted in the allegations include:
- Presumptively placing patients in the Ultra High therapy reimbursement level, rather than relying on individualized evaluations to determine the level of care most suitable for each patient’s clinical needs
- Providing the minimum number of minutes required to bill at a given reimbursement level while discouraging the provision of additional therapy beyond that minimum threshold
- Increasing therapy minutes only during the period in which billing levels were set
- Pressuring therapists and patients to complete the planned minutes of therapy regardless of patient need, and in some cases, for patients for whom such therapy would have been dangerous
U.S. Attorney Kurt R. Erskine stated, “Nursing home facilities provide important services to our elderly; however, those facilities must uphold the trust placed in them by billing the government only for reasonable and necessary services. This settlement demonstrates our continuing efforts to protect patients and taxpayers by ensuring that the care provided to beneficiaries of government-funded healthcare programs is dictated by clinical needs, not a provider’s fiscal interests.”
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 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 being provided to residents are reasonable and necessary. To avoid a “reverse false claim” (i.e., an overpayment), make all reasonable efforts to determine if inappropriate billing occurred, if any related overpayments exist, and if found, return the funds to Medicare within 60 days of identification.
