Medicaid Nursing Facility Fraud: The Signature Came Before the Assessment

SNF Medicaid fraud can begin with a forged admission certification or an inflated care assessment that changes what a state Medicaid program pays. In a skilled nursing facility, the admission paperwork says a physician approved the placement. The assessment says the resident needs a higher level of care. Taxpayers bear the cost when those judgments are invented. If you work in nursing, admissions or billing, you may know who actually made those decisions and what the forms said instead.

Medicaid Nursing Facility Payments Start With State Rules

Medicaid nursing facility payment follows state coverage and payment rules. A facility certified for both Medicare and Medicaid can receive payment under different programs for different care. The resident can stay in the same room while the payment basis changes.

The MACPAC payment-policy brief describes daily rates built from such components as direct care, other operating expenses and capital. States can adjust those rates for residents’ care needs, occupancy and other factors. Cost reports can support a cost-based rate or help set a prospective price. Case mix adjusts payment for care needs within either approach.

That gives a false record more than one place to affect payment. An admission certification can support approval for covered care. An inflated assessment can increase the amount paid. The person creating the record may work well before the billing department ever sees it.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Photocopied Physician Signatures on Medicaid Admission Certifications

In the Vanguard Healthcare case, the government alleged that nursing homes used photocopied physician signatures on Medicaid admission certifications to obtain TennCare payments. The government’s complaint describes blank forms bearing the signature before staff entered the resident’s assessment information.

TennCare is Tennessee’s Medicaid program. The complaint describes pre-admission evaluations, known as PAEs, used to determine medical eligibility for nursing facility care. Under the requirements described there, one certification confirmed the assessment was accurate. A physician separately signed and dated the form to confirm the resident needed that care.

Preadmission screening and resident review forms, known as PASRRs, addressed a different question: whether the resident had or might have a mental illness or intellectual disability requiring further evaluation or specialized services.

The government’s account of what happened to those signatures is unusually concrete:

The alleged sequence reversed the purpose of the form. Medical approval was already on the blank page. The resident’s information came afterward.

At Imperial Gardens, the government alleged a separate signature substitution. An administrator without a Tennessee nursing license filled out the assessment and instructed a medical records clerk to add a nurse’s electronic signature. According to the complaint, that nurse had neither performed the assessments nor authorized the use of her name.

The payment connection was explicit. The government alleged that TennCare would have denied approval through CHOICES, its program for long-term services and supports, and refused the affected long-term-care claims because the certifications carried forged signatures.

Vanguard settled the federal and state claims in 2019. The government’s allegations covered deficient nursing care as well as forged admission paperwork. Those allegations included failures in medication, infection control and wound care.

Tennessee Health Management’s Placement Evaluations

Tennessee Health Management agreed to pay more than $9.7 million in 2019 to resolve allegations involving the same kind of certification shortcut. The Justice Department alleged that the company submitted pre-admission evaluations with photocopied or pre-signed physician signatures on certifications required for TennCare nursing facility claims.

The agreement allocated payments to both the United States and Tennessee. The placement evaluation was supposed to carry a physician’s evaluation and certification for the patient entering the home. The alleged practice substituted a signature already available to staff. For someone handling admissions, the decisive question is whether the physician actually made the judgment attributed to that signature.

Inflated Care Assessments Can Raise the Medicaid Rate

State Medicaid case-mix payments can rise when submitted assessments say residents need more care. The Grand Health Care System’s Pawling facility provides a specific New York example.

In the company’s 2024 settlement agreement, the government alleged that management employees submitted data to the New York State Department of Health that overstated residents’ care needs, including rehabilitation services. According to the government, those submissions distorted individual residents’ RUG care-need scores, raised the facility’s Case Mix Index and increased Medicaid payments.

The chain was concrete: the reported care need changed the resident’s score, which changed the facility’s payment measure. Staff who knew the resident’s condition could see the starting discrepancy. People preparing the state submission could see how that discrepancy reached the rate.

The agreement also contains Grand’s admissions about Medicare therapy quotas and altered treatment minutes. Its Medicaid allegations concern Pawling’s separate submissions to New York.

When a Therapy Settlement Also Covers Forged TennCare Certifications

A forged TennCare certification can sit inside a nursing facility therapy settlement. Signature HealthCARE and Diversicare show why the Medicare therapy claim and the Medicaid admission claim need separate attention.

Signature HealthCARE’s 2018 settlement announcement described allegations that residents were presumptively placed at the highest therapy reimbursement level and pressured to complete therapy even when sick or unwilling. The settlement also resolved allegations of forged pre-admission certifications of skilled-nursing need sent to Tennessee Medicaid. The therapy record and the admission certification served different payment decisions.

Diversicare agreed to a $9.5 million settlement in 2020 covering Medicare rehabilitation claims and TennCare admission certifications. The government’s Medicare allegations included unnecessary therapy, reimbursement quotas and inflated activities-of-daily-living scores. Its TennCare allegations concerned forged, photocopied or pre-signed physician signatures on pre-admission evaluation certifications.

The whistleblower’s Diversicare complaint described how pressure could reach an assessment:

That allegation describes an assessment repeated until management accepted the number. In the separate TennCare allegation, the signature supplied the appearance of approval. Both put the people making the clinical record between the resident’s actual needs and the payment the company wanted.

Cost Reports and Resident Contributions Change the Payment Too

Medicaid nursing facility payments also depend on financial information outside the clinical chart. A cost report supplies information used in setting rates. A resident’s required income contribution, after deductions for personal needs and other protected expenses, can reduce what Medicaid pays.

The Tennessee Comptroller’s 2019 audit announcement described nonallowable AltaCare home-office expenses allocated to Cambridge House. It estimated resulting Medicaid overpayments of $324,999. The accounting connection ran from the parent’s expenses through the facility’s allocated costs to reimbursement. Staff working with home-office allocations see a different part of the payment calculation from a nurse completing an admission assessment.

What Evidence Is Needed to Prove Fraud?

We work with you to connect the admission certification or care assessment to the clinical record, the person who certified it, the claim and the Medicaid payment. The state program and its payment rules are part of that work.

For an admission-certification case, the connection runs through the assessment, the signature, its date and the approval that supported payment. Vanguard’s complaint made the distinction between the person named on a form and the person who actually completed it visible. It also alleged that corporate billing staff pressed for prompt evaluations to avoid losing TennCare reimbursement.

For an assessment case, the underlying observations and the version sent to the state show what changed. Grand’s Pawling allegations connect that change to the facility’s case-mix measure. Nursing staff, assessment coordinators and billing employees can each see a different part of that chain.

What Is a Red Flag for Health Care Fraud?

A signature on a blank assessment, a nurse’s name used for an assessment the nurse never performed, or repeated assessments aimed at a higher score are concrete red flags for health care fraud. What matters is who decided what went on the form and how it changed the payment.

A 2018 teaching paper in the Journal of Forensic & Investigative Accounting examines workplace fraud through pressure, opportunity and rationalization, including the ability to bypass controls. The reimbursement demand explains the target, while control over assessments and signatures explains how it could reach a claim.

An insider’s account can connect those decisions. If you know why a signature appeared before the assessment or why an assessment changed before submission, we can work from that knowledge to examine the payment and the people directing it.

When You Know How the Form Got Completed

If you know who supplied a copied signature, ordered a higher care score or submitted an assessment the clinical record could not support, talk with our whistleblower experts about the Medicaid payments behind it. We work beside you to build the case around those decisions and bring in Medicaid fraud whistleblower lawyers who understand nursing facility certifications and state payment systems. We stay with you from the first conversation through the case, putting your knowledge of the paperwork to work against the people directing the fraud.