Fraud goes 'hand in hand' with nursing home quality concerns

State and federal officials across the country are using fraud allegations to target nursing homes accused of providing poor quality care often tied to insufficient staffing.

Last week, the Department of Justice announced it was launching 10 regional Elder Justice Task Forces targeting nursing homes "that provide grossly substandard care to their residents." Although the announcement focuses largely on quality care concerns, the task forces appear rooted in fraud enforcement. Teams will include representatives from the Medicaid Fraud Control Units, local prosecutors and the U.S. Attorney's Office.

In remarks introducing the new task forces, Principal Deputy Assistant Attorney General Benjamin C. Mizer pointed to a $38 million settlement with Extendicare Health Services Inc. in 2014, which resolved allegations the provider improperly billed Medicare and Medicaid while staffing an insufficient number of skilled nurses. Keesha Mitchell, president of the National Association of Medicaid Fraud Control Units, also commented that resident abuse and fraud often "go hand in hand."

In New Mexico, the state attorney general has filed a lawsuit against seven nursing homes currently owned by Preferred Care Partners Management Group and previously owned by Cathedral Rock Corporation. In addition to testimony from 36 confidential witnesses that outlined lapses in basic care, the Attorney General's Office calculated the minimum time required to care for each resident and compared that to self-reported staffing data at each facility. Investigators determined it was not "physically or mathematically possible" for the nursing facilities to meet basic care needs with the staffing levels they reported.  

The lawsuit indicates that the nursing facilities in question "generated revenue in excess of $236 million" since 2008, nearly 80 percent of which came from Medicare and Medicaid.

Skilled nursing facilities (SNFs) and nursing homes have been in the government's crosshairs, with the Office of Inspector General reporting that Medicare overpaid SNFs $1.1 billion in 2012 and 2013 and calling for the Centers for Medicare & Medicaid Services to rework the payment system. Following RehabCare's $125 million settlement in January, attorneys told FierceHealthPayer: Antifraud that therapy benchmarks have emerged as a red flag for false claims. 

To learn more:
- read the DOJ announcement
- here are Benjamin C. Mizer's remarks
- read Keesha Mitchell's comments
- see the New Mexico Attorney General's lawsuit