Nursing Home Fraud

Nursing homes, or skilled nursing facilities (SNFs), are typically long-term care providers that offer rehabilitation and personal care services. Typically, these facilities play an integral role in patient recovery when quality care is administered; however, a report from the Office of the Inspector General (OIG) found that a staggering 74% of these homes were not providing care that met federal standards. Further, many skilled nursing facilities submit an array of false claims to both Medicare and Medicaid, receiving billions in inappropriate reimbursements from both government-funded healthcare programs.

Medicare instates certain quality-of-care requirements in order to determine eligibility for claims payment; in the case of skilled nursing facilities, each beneficiary must be provided with a care plan that outlines their individual medical, nursing, and psychosocial needs, as well as a description of how these needs will be met. In comparison to other types of healthcare facilities, these requirements are fairly simple, thus creating the opportunity for fraudulent activity to arise. 

Nursing Home Fraud Includes

Some of the most common practices used to perpetuate nursing home fraud include:

  • Lack of care plan development, leading to insufficient or non-rendered treatment
  • Submitting falsified claims that exaggerate patient illnesses in order to receive higher reimbursement rates
  • Performing services, running lab tests, or administering drugs that are not medically necessary
  • Alleging inflated amounts of employee work hours to support claims that care was administered
  • Double-billing for services or treatments
  • Providing kickbacks in exchange for patient referrals
  • Submitting claims for goods, services, or tests that were not performed
  • Forging physician signatures to bill for doctor rates, when the services were performed by a nurse or other employee

These fraudulent practices directly contribute to the estimated $60 billion in annual Medicare losses; a 2009 OIG study reported that one-quarter of the claims billed by skilled nursing facilities were done so in error, resulting in the program paying $1.5 billion in inappropriate SNF reimbursements that year. This figure denotes the blatant exploitation of federal healthcare programs as a whole – a burden that is felt by the taxpayers who consequently foot the bill.

Whistleblowers play an important part in uncovering these discrepancies, many of whom are employees of these facilities; the detriment caused by these schemes goes far beyond the depletion of government funds, as it can often result in the neglect and abuse of beneficiaries in their purported “care.” The conditions in which these patients are subjected to can be deeply troubling, and often go unnoticed without the assistance of a whistleblower.

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