Saber Healthcare: The Therapy Targets Behind a Medicare Settlement

In the Saber Healthcare fraud case, Saber Healthcare Group LLC agreed to pay $10 million to resolve allegations that it pushed unnecessary rehabilitation and counted evaluations and unskilled work as therapy. The government’s account put the facility budget at the center of the treatment decision: staff allegedly faced pressure to reach Ultra High therapy targets even when clinical judgment called for less.

The Justice Department announced the settlement on April 14, 2020. At the time, Saber was based in Bedford Heights, Ohio, and operated skilled nursing facilities in seven states. Former Saber rehabilitation therapists and therapy managers brought the case as whistleblowers. It concerned Medicare payments for rehabilitation services.

Ultra High Targets and Unskilled Work

The government alleged that Saber used uniform Ultra High therapy targets and budget expectations that displaced clinical judgment. According to the government, Saber pressured facility directors in weekly or daily calls to make sure therapists gave each patient Ultra High therapy, and prevented therapists from providing lower levels of therapy minutes when their clinical judgment called for less. Residents allegedly received therapy they did not need, and Medicare got the bill.

According to the Justice Department’s account of the allegations, Saber also counted evaluations and unskilled services as therapy. The treatment total allegedly included work that did not qualify as skilled therapy.

Assessing a resident and providing treatment are different parts of a therapist’s work. We look at what the entry describes, what service the resident received, and how that entry affected the claimed therapy level.

Financial pressure also has an organizational trail. The 2018 Journal of Forensic & Investigative Accounting teaching paper Pressure to Commit Fraud in the Workplace: Two Teaching Cases Addressing Fraud and Whistleblower Protection reports a finding from the 2016 Global Fraud Survey: one third of respondents would justify illegal payments to increase business during an economic downturn or under pressure to meet financial targets. That finding makes the source of a target worth examining, alongside what staff did to meet it. Who set the target, who passed it down, and how did they respond when the treatment assessment called for less?

Why the 720-Minute Threshold Mattered

Under Medicare’s old payment system, the Ultra High category required at least 720 minutes of therapy in a week from two disciplines, with one provided five days a week. Reaching the category affected Medicare reimbursement. A facility target expressed in therapy minutes therefore carried a payment consequence.

The government said the pressure to meet the target displaced the judgment that should have determined the resident’s treatment. For an insider, the important connection is between the clinical assessment, the expected therapy level, and the minutes that ultimately supported the bill.

The Patient Driven Payment Model replaced that system for Medicare skilled nursing payment on October 1, 2019, under CMS’s payment rule. The newer model uses resident characteristics, including diagnoses, function, nursing needs and nontherapy ancillary needs, to classify payment. That change moved the financial importance of particular assessment entries.

The Facility Name and the Business Behind It

The settlement covered homes including Emerald Health and Rehab Center and Amberwood Manor. At seven facilities, the covered period ran from January 2013 through March 2017. Autumn Care of Altavista and Waddell had a later start, in March 2016.

The HHS Office of Inspector General’s integrity-agreement listing identifies Harnett Healthcare Group, LLC as doing business as Emerald Health and Rehab Center. The facility’s familiar name and the company behind it can appear on different records.

We match the operating name to the business that submitted the claim and to the people who controlled the therapy expectation. The name on the building is the beginning of that inquiry.

What Evidence Is Needed to Prove Fraud?

For a therapy-target case, the evidence connects the resident’s condition and actual treatment to the assessment, the Medicare claim and the people directing the work. Clinical notes, assessment versions, therapy logs, schedules and billing records show different parts of that connection. We examine them together.

The Resident’s Assessment and Treatment

The Minimum Data Set is part of the resident assessment. Nurses, therapists and other clinical staff supply information about the resident, while physicians and eligible practitioners supply orders and certifications. An assessment form can therefore be compared with the observations and treatment records behind it.

For the Saber allegations, we would examine what the therapist assessed, what treatment the resident received, and what the therapy log counted. The distinction between evaluation time, skilled treatment and unskilled work is central. So is the relationship between a clinical recommendation and a therapy level that management expected the facility to maintain.

The Budget and the Staff Doing the Work

Payroll, schedules, time records and contractor invoices can help connect the people doing the work to the services recorded for payment.

We would compare the stated expectation with the treatment entries and examine who directed any change. An insider may know why an entry changed or why a recommendation did not change the schedule. That account helps us understand the records in the context of the work, including who had authority over the decision.

The Facility’s Claim and the Contractor’s Invoice

Under Medicare’s skilled nursing payment system, consolidated billing makes the facility responsible for many services delivered by outside providers. Medicare pays the facility, and its contract determines payment to the supplier. A therapy company can therefore hold treatment records while the facility holds the resulting Medicare claim.

We connect those records through the resident, service dates and billing information. Contracts and management agreements help identify who provided the service and who controlled the expectation. That is why a therapist, assessment coordinator, administrator, biller or contractor may each see a useful part of a health care fraud case without seeing every part of the payment.

How Much Does a Medicare Fraud Whistleblower Get Paid?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The Justice Department announced a collective whistleblower reward of $1.75 million in the Saber case.

The settlement also required a five-year corporate integrity agreement with independent annual review.

Therapy Targets in Other Nursing Home Cases

Life Care Centers of America faced a similar allegation that planned therapy minutes followed the reimbursement category. The government’s complaint described an instruction from a rehabilitation manager that made the priority explicit:

The same complaint alleged that therapy increased during payment assessment periods and decreased afterward without a clinical reason for the change. The instruction and the treatment pattern tell the same alleged story: the billing category was setting the pace.

In a separate whistleblower complaint against Strauss Ventures, whistleblowers alleged that staff added treatment minutes that had never been delivered to meet projected metrics. They also alleged that time spent persuading residents to participate counted as therapy.

The recurring question is how the demand for a particular payment category changed the treatment record. For someone who worked under that demand, the instruction behind an entry may be as revealing as the entry itself.

You Know How the Therapy Target Reached the Chart

If you saw a therapy target override a resident’s needs, speak to one of our whistleblower experts about how the target reached the chart. We work with you to build your strongest healthcare fraud whistleblower case, bring in Medicare therapy fraud whistleblower lawyers, and remain your partners as the case moves forward.