SavaSeniorCare: Therapy Targets, Delayed Discharge and the Care Case

In the SavaSeniorCare fraud case, the nursing-home operator agreed to pay approximately $11.2 million to resolve allegations of unnecessary therapy, delayed discharges and grossly substandard care. Behind the settlement were decisions a facility insider would recognize: the therapy category management wanted, the patient staff said could go home, and the paperwork that allegedly kept Medicare paying after skilled care was no longer needed.

The Justice Department announced the settlement on May 21, 2021, resolving allegations from four qui tam cases filed by whistleblowers in Tennessee and Pennsylvania. Sava operated skilled nursing facilities providing short-term rehabilitation and longer-term care. The complaints brought the story inside those facilities, including an account from a social-services director who handled discharge planning at Lebanon Health and Rehabilitation Center in Tennessee.

Therapy Targets That Reached the Discharge Desk

After joining part of the whistleblowers’ case, the government alleged that Sava pressured facilities to reach the highest Medicare therapy payment categories without regard to patients’ clinical needs. Its therapy allegations covered October 2008 through September 2012 and included medically unnecessary or unskilled services and delays in discharging patients who were ready to leave.

That was the era when Medicare paid facilities a daily rate tied to Resource Utilization Groups. Therapy volume helped determine the payment category. Keeping a patient in a higher category and keeping that patient in the facility longer could increase the bill in different ways. The allegation was that financial targets drove both decisions.

A separate whistleblower complaint concerning Woodwind Lakes Health and Rehabilitation Center described an alleged incentive inside the management structure. It alleged that administrators and nursing directors received quarterly bonuses tied to Medicare Part A billing and a high Medicare patient census. The whistleblower was a social worker who had previously worked as a state nursing-home surveyor.

According to that complaint, Woodwind Lakes and other named facilities kept patients for the full 100 days of their Medicare benefit even after rehabilitation staff assessed that skilled care was no longer needed. The complaint then described what allegedly happened when the money stopped:

The alleged concern about a patient’s readiness ran in opposite directions depending on whether Medicare days remained. Staff assessments could call for discharge while the facility kept billing, then the benefit could run out and the patient would be sent away.

Medicare replaced therapy-minute classification with the Patient-Driven Payment Model on October 1, 2019. Diagnosis, function, nursing characteristics and other clinical needs became the payment inputs. Sava’s therapy allegations concern the earlier system, when minutes and payment categories made the rehabilitation department a direct focus of revenue pressure. Under PDPM, unsupported diagnoses or assessments on the Minimum Data Set can change the payment category and the bill.

How Discharges Were Allegedly Delayed at Lebanon Health

The Lebanon Health whistleblower alleged that staff altered records to make patients appear to need more care, or to need skilled services after that need had ended. Her amended complaint described morning meetings where department heads discussed admissions and discharges. Care-plan meetings determined the RUG rates used for Medicare billing, and the clinical evaluations fed physician orders and bills.

That put the discharge planner at the intersection of what patients were told, what clinical staff recommended and what the facility claimed it was providing. The complaint identified alleged false Medicare and Medicaid certifications and recertifications for six patients.

A Reason to Stay Came After the Decision

In one episode, a patient wanted a replacement hospital bed delivered to her home and time to rearrange her furniture. The whistleblower alleged that the administrator told her to find a way to extend the stay until the bed arrived and the furniture was moved. Medicare allegedly paid for medically unnecessary care while that happened.

Another patient was already paying to hold a bed at a long-term care facility. According to the complaint, the administrator or someone acting for her told the patient’s daughter that the patient was not ready to leave Lebanon Health. The daughter disagreed and came to take her mother back. In the whistleblower’s account, the administrator was trying to keep a medically ready patient in the facility.

The alleged instruction to staff was broader than those examples. The social-services director said she was told to get physical therapy, occupational therapy or nursing staff to find reasons to extend stays. When patients and families asked why they could not leave, she was allegedly instructed to say that Medicare would not pay if they did.

The paperwork was supposed to explain why the patient needed care. In this account, staff first received the decision to keep the patient and then had to produce the reason.

The Discharge Limit Left a Paper Trail

The original complaint alleged that falling rehabilitation occupancy brought pressure to increase the census. The administrator allegedly told the social-services director to allow no more than one Medicare discharge a day.

The complaint also described what happened to signed discharge forms when a stay was extended. The administrator allegedly directed the discharge planner to retain the family’s signed form without crossing out the discharge date, create a new form, and put the signed form behind it as a secondary page. The stated purpose was to prevent a reviewer from questioning multiple discharge forms.

Managed-Care Review Changed the Alleged Practice

The Lebanon Health complaint drew a distinction between ordinary Medicare patients and those in Medicare managed care. It alleged that the false certifications were used for the former, while managed-care case managers would not permit the extended stays. The administrator allegedly avoided the same record falsification for those patients because the stays could not be extended.

Healthcare payment arrangements help explain why that comparison matters. The California Research Bureau’s 1997 report, Fraud and Abuse in the Health Care Market of California, contrasted fee-for-service incentives to increase services with capitation’s incentive to contain their cost:

The Sava complaint supplied the facility-level comparison: an alleged extension practice that changed when an outside case manager could refuse it. An insider familiar with both sets of patients could see a difference that a total Medicare billing figure would conceal.

Why Medicare and Medicaid Both Appear

Medicaid was part of the Sava therapy case because it covered coinsurance for some residents who qualified for both programs. The government’s allegations included Medicaid coinsurance claims tied to the disputed therapy services.

The payment structure described in the complaint gave the resident’s bill a role of its own. Medicare paid for covered services during the first 20 days of a qualifying skilled nursing stay. A daily coinsurance obligation then applied to the remaining covered days, with Medicaid covering that obligation for some dual-eligible residents.

The Lebanon Health whistleblower alleged another way of keeping residents in the building: waiving their Medicare copayments to encourage longer stays. She said the administrator knew that the cost would otherwise make many patients leave or refuse an extension, and directed staff to tell patients to discard the bills. The amended complaint quoted the administrator’s reassurance:

According to the complaint, the waivers reduced the patient’s cost without reducing Medicare’s cost. It alleged that the waivers were unlawful inducements to remain. The patient could ignore the bill while the facility continued billing the government for the extended stay.

Those allegations connect different records: the discharge recommendation, the certification of continued skilled need, the resident’s bill and the claim to the public payer. Someone in the business office could know what happened to a copayment without attending the meeting where the stay was extended.

The Care Case Reached the Bedside

The government also alleged that Sava knowingly submitted false claims to Medicare and Medicaid for grossly and materially substandard or worthless skilled nursing services. That component covered January 2008 through December 2018, a different period from the therapy allegations.

The Justice Department’s account identified insufficient staffing, failures to follow pressure-ulcer and falls protocols, and medication failures. Residents allegedly went without needed nursing care while taxpayers paid the bills.

The resulting corporate integrity agreement required staffing policies based on residents’ care needs and tracking of temporary staffing. Sava also had to notify the independent monitor of known deaths or injuries related to restraints, psychotropic medications, or abuse or neglect.

For a nurse or aide, the relevant experience is what care the resident needed and received on the shift. For a payroll or staffing employee, it is who actually worked. Connecting those accounts to the billed services is how we examine the care allegation with an insider.

What the SavaSeniorCare Settlement Required

The settlement amount reflected Sava’s ability to pay, with additional payments dependent on financial contingencies. The resolution also required a five-year corporate integrity agreement with the Department of Health and Human Services’ Office of Inspector General. Its oversight reached both the claims sent to Medicare and the care delivered to residents.

An independent review organization had to examine patient stays and the paid claims associated with them. The review reached the orders, assessments and discharge planning behind each bill, including whether the medical record supported the Minimum Data Set information affecting payment. It also covered whether rehabilitation was appropriate to improve a patient’s condition, maintain it or slow deterioration.

A separate independent monitor, selected by the Inspector General’s office after consultation with Sava, had authority to visit facilities without prior notice and obtain staffing data and resident records. The agreement provided for interviews with residents and covered personnel outside the presence of Sava’s supervisors.

The distinction matters inside a facility. A claim reviewer compares the bill with the clinical support. A care monitor can also watch care being delivered, speak with staff and residents, and examine whether the systems meant to correct problems are working. Sava’s agreement required both kinds of scrutiny.

What Evidence Is Needed to Prove Fraud?

In a case about therapy targets and delayed discharge, the evidence connects the resident’s actual needs to the assessment, the instruction to staff and the claim the government paid. We examine who changed the account of the patient’s condition, who directed the change and how it affected billing.

The Lebanon Health complaint shows why the original discharge recommendation, later certifications and successive discharge forms matter together. Therapy notes and treatment logs can show what clinicians assessed and provided. Assessment versions, orders and billing records show how that clinical work became a payment claim. A bonus formula or census instruction can explain the financial pressure behind a decision.

The care side calls for a different comparison within the same stay. Nursing notes and care plans describe the resident’s needs and treatment. Payroll, schedules, time records, agency invoices and staffing contracts help identify the people available to deliver it. We connect those records to the facility’s claims, with the insider who understands what the entries meant in daily practice.

Life Care Shows the Same Pressure on Clinical Decisions

Life Care Centers of America agreed to a $145 million settlement in 2016 over allegations involving unnecessary rehabilitation and prolonged stays. In that separate case, the government’s complaint alleged that therapy increased during payment assessment periods and fell afterward without clinical justification. It also described therapy continuing after repeated discharge recommendations until the patient’s Medicare benefit ran out.

The shared allegation is recognizable to rehabilitation staff: a clinical recommendation loses to a payment target. The records that show it can sit in different departments, with a therapist’s recommendation in one place and the assessment or bill in another.

You Know Why the Patient Stayed

If you saw a discharge decision reversed to protect Medicare revenue, or care billed that residents did not receive, talk with our whistleblower experts. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We work beside you throughout the case to build your strongest skilled nursing whistleblower case and bring in skilled nursing fraud whistleblower lawyers who understand therapy billing and resident care.