England Associates New London Health Center: Therapy Planned Around a Billing Target

In the England Associates New London Health Center fraud case, England Associates agreed to pay $400,000, an amount based on its ability to pay, to resolve allegations of Medicare therapy billing fraud. The government alleged that the nursing home treated reimbursement targets as treatment targets, pushing patients toward a billing category and therapists toward the minutes needed to reach it. For someone who worked under those demands, the question is: who decided how much therapy a patient would receive, and what drove that decision?

England Associates, L.P. operated as New London Health Center. The Department of Justice’s Northern District of Georgia office announced the settlement on March 11, 2022. The government alleged that the home knowingly submitted claims for rehabilitation services that were unreasonable, unnecessary and unskilled.

How New London’s Therapy Targets Allegedly Worked

The government alleged that New London shaped therapy around reimbursement between January 1, 2011 and November 30, 2014. Its account described decisions about the level of treatment, the amount delivered, the timing and the pressure to finish it.

First came the category. New London allegedly presumed that patients belonged in the Ultra High therapy reimbursement level, instead of using individualized evaluations to determine the care each patient needed. In that account, the financial destination came before the clinical judgment.

Then came the stopping point. The government alleged that New London provided the minimum minutes needed to bill at a particular reimbursement level while discouraging therapy beyond that threshold. That is the revealing part of the allegation: staff allegedly faced pressure to deliver enough therapy to qualify for the payment, and pressure against delivering more once the target was met. As alleged, the billing threshold worked in both directions.

The timing mattered too. New London allegedly increased therapy minutes only during the period used to set billing levels. The government described a treatment schedule following the payment assessment, rather than the patient’s individual needs.

Finally, the government alleged that New London pressured both therapists and patients to complete planned minutes regardless of patient need, including some patients for whom the therapy would have been dangerous. That puts the alleged conflict inside the treatment session. In that account, the patient was expected to finish a financial target dressed as a care plan, at taxpayers’ expense.

Why Ultra High Therapy Minutes Mattered

The historical RUG-IV payment system grouped residents for payment partly by therapy minutes. The Justice Department’s description of the Ultra High category specified at least 720 minutes a week across two therapy disciplines, with one furnished five days a week. A minutes target could therefore become a payment target.

New London’s alleged conduct fell within the RUG-IV era. Assessments during that era set payment levels for designated portions of a resident’s stay. That explains the significance of the allegation about increasing treatment during the assessment period: the recorded therapy helped determine what Medicare would pay beyond the treatment session itself.

Medicare replaced RUG-IV with the Patient Driven Payment Model on October 1, 2019. Under the replacement model adopted by the Centers for Medicare & Medicaid Services, resident characteristics drive payment classification. New London’s case concerns the earlier incentive to reach therapy-minute thresholds. Under the newer model, diagnoses and assessments of a resident’s function help determine payment. The assessment still connects the clinical record to the Medicare bill.

What Evidence Is Needed to Prove Fraud?

For a therapy billing case, the useful evidence connects the patient’s clinical needs, the treatment delivered, the assessment and the claim sent to Medicare. We examine that connection with the insider who knows how the facility actually made those decisions.

Therapy logs, clinical notes, orders and versions of the Minimum Data Set resident assessment connect the care recorded to the payment classification used on the bill. We read them with you to understand how a treatment decision became a billing decision.

An outside therapy provider can deliver the treatment while the facility submits the claim. Under Medicare’s bundled billing arrangements, Medicare pays the skilled nursing facility, while its contract determines payment to an outside supplier. That division matters when we work with you to trace who controlled the therapy targets.

The pressure itself deserves attention. The 2018 Journal of Forensic & Investigative Accounting teaching paper Pressure to Commit Fraud in the Workplace: Two Teaching Cases Addressing Fraud and Whistleblower Protection discusses financial targets and management pressure as warning signs. In a healthcare case, we connect a therapist’s account of demands to finish planned minutes to the clinical record and the resulting bill.

A Therapy Memo in the Life Care Case

A separate government complaint against Life Care Centers of America alleged a similar conflict between planned minutes and clinical judgment. It quoted an instruction to rehabilitation staff:

The instruction, as quoted in that complaint, gives a reason for keeping the minutes: reaching a category by a date. That is what an internal directive can add to a therapy log. The log records the minutes. The directive can explain why staff were expected to deliver them.

A Whistleblower’s Share of the Recovery

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. If your work in nursing home health care, assessments or billing exposed pressure to put reimbursement ahead of patient need, speak to one of our whistleblower experts about the case that knowledge supports.

You Know Who Set the Therapy Target

If you saw patients pushed to finish minutes to meet a billing target, tell our whistleblower experts what drove the treatment schedule. We work beside you to build the case from the care decisions through the Medicare claims, and bring in nursing home fraud whistleblower lawyers who understand therapy billing. You bring the experience inside the facility, and we stay with you through the pursuit of a recovery.