Tennessee Health Management: Photocopied Signatures on Medicaid Admission Certifications

In the Tennessee Health Management fraud case, the company agreed to pay $9,764,108 to settle allegations that it used photocopied or pre-signed physician signatures on TennCare admission certifications. The allegation went to a basic promise in the admission file: that a physician had evaluated and certified the patient’s nursing-home placement. The people who handled those forms could explain what a finished file might hide: how the physician’s signature got there.

The Justice Department announced the settlement on February 5, 2019. Tennessee Health Management Inc. operated 27 skilled nursing facilities in Tennessee at the time. The government’s allegations concerned claims for nursing-facility services submitted to TennCare, Tennessee’s Medicaid program.

Why the Physician’s Certification Mattered

TennCare required a physician to conduct and certify a placement evaluation for each patient entering a nursing home. That gave the signature a job: it connected the patient’s admission paperwork to a physician’s evaluation of that patient’s placement.

The United States and Tennessee alleged that, from January 1, 2010 through December 31, 2017, Tennessee Health Management submitted pre-admission evaluations bearing photocopied or pre-signed physician signatures on the required certifications. A physician’s name appeared where the program expected that physician’s certification. The alleged shortcut was in how that approval reached the form.

Here, the disputed forms supported TennCare placement and the associated Medicaid claims. Taxpayers were being asked to fund nursing-home care on the strength of those certifications. Residents depended on the physician’s evaluation of their placement, not merely the appearance of a signature in the file.

What Evidence Is Needed to Prove Fraud?

We work with insiders to connect what happened in the facility to what the admission file told TennCare. In a health care fraud case about physician certifications, the finished form may reveal less than the employee who knows how it was prepared.

An admissions employee may recognize a form that arrived already signed. A clinician may know whether the evaluation described in the file took place. A billing employee may know which admission record supported the TennCare claim. The value is in connecting those accounts to the same patient, facility and claim.

Management instructions and responses to internal concerns can explain how a signature practice became routine. That is why an account of who prepared the paperwork can matter as much as the final copy.

When the Signature Came Before the Patient Information

In the government’s separate case against Vanguard Healthcare, the complaint alleged that facilities used blank forms with photocopied physician signatures already on them. It described the sequence plainly:

According to that complaint, the physicians whose signatures appeared on the forms never certified their accuracy before submission. It also alleged that investigators were shown a binder containing 30 pre-printed evaluation forms with a physician signature already present.

The doctor’s approval was waiting in a binder for the patient information. A finished admission file could conceal the order in which staff assembled it.

The government’s account went beyond finding a stack of forms. Nurses at Manchester allegedly told investigators they always used forms with physician signatures already on them before adding patient information. One said she had completed pre-admission screening forms that very morning using copied signatures and had been trained to do it that way. The alleged shortcut had become the way the work was taught.

The complaint described a separate problem with a nurse’s certification at Imperial Gardens. An administrator allegedly directed a medical records clerk to place the nurse’s electronic signature on the assessment portion of a level-of-care form. According to the government, that nurse had neither performed the assessments nor authorized the use of her name. The name on the form and the person who did the work were different stories.

Corporate knowledge mattered too. The government alleged that a Vanguard corporate official said someone would visit Imperial Gardens and conduct an audit, but the company did neither and allowed the forgery practices to continue. That allegation makes management’s response part of the signature story: who learned about the practice, what they said they would do and whether anything changed.

The Vanguard complaint also connected the forms directly to payment. The government alleged that TennCare would have denied approval for the affected residents’ long-term care coverage had it known about the forged certifications, and would not have paid the resulting claims. The signature question reached all the way to payment.

Admission Certifications in Other Tennessee Settlements

Signature HealthCARE’s June 2018 settlement also covered allegations of forged pre-admission certifications of skilled-nursing need sent to Tennessee Medicaid.

Diversicare’s February 2020 settlement likewise covered allegations of forged, copied or pre-signed physician certifications for TennCare placement. The repeated issue was a document carrying a physician’s approval of placement.

Tennessee Health Management’s settlement centered on that admission-certification practice. We focus with the insider on the physician’s placement certification, the clinical information behind it and the TennCare claim it supported.

The Settlement Payment and Integrity Agreement

The settlement allocated $5,455,207 to the United States and $4,308,901 to Tennessee.

The resolution also required a corporate integrity agreement with the Department of Health and Human Services Office of Inspector General. OIG’s company entry identifies a five-year agreement, effective February 1, 2019, in its claims-review category. The listing marks the agreement closed, with its effective period ending November 4, 2024.

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

You Know How the Forms Were Completed

If you know how physician signatures reached nursing-home admission forms, speak to one of our whistleblower experts about how those signatures got there. We connect your knowledge of the clinical work and billing process to your strongest skilled nursing facility whistleblower case, and bring in healthcare fraud whistleblower lawyers who understand Medicaid certification disputes. We stay beside you as partners throughout the case.