Fraud

Fraud is defined as wrongful or criminal deception intended to result in financial or personal gain.  Fraud committed by nursing homes and other healthcare facilities through government funded programs, such as Medicare and Medicaid, has become an expensive problem in the United States.  Medicare and Medicaid are government programs that pay for certain nursing home charges and other medical bills.  When Medicare and Medicaid fraud is committed, the government pays billions of dollars in fraudulent charges, essentially paid by taxes.  This is why there are whistleblower actions, which reward identification of some of these fraudulent schemes.  There are several different ways in which a nursing home can commit fraud:

Upcoding: There is one form of fraud committed by nursing homes called “upcoding.” Upcoding is billing services using billing codes for a different, but maybe similar service, which is reimbursed at a higher rate than the service actually provided.

Phantom Billing: Another example of fraud is placing the nursing home resident into a higher level of care than they actually need or want.  Medicare then reimburses the nursing home the highest rate for the resident.  The resident then undergoes treatment or therapy that is medically unnecessary. This scheme could be applicable to any number of services where the resident is receiving, and paying for, unnecessary services.

Billing for Services Not Provided:  This form of fraud is the most straight forward.  It is like flat out stealing money.  This can occur where a resident does not receive physical therapy, but is billed for physical therapy or is billed for more therapy than is provided.

Kickback: Kickback fraud occurs when a person or company receives some form of compensation as part of a fraudulent scheme, whether billing for services not provided, billing for unnecessary treatment, up-billing or up-coding or other scheme.

Unbundling: Another form of nursing home fraud is when nursing homes either bill one resident for a “kit” of supplies, but doesn’t use all of the supplies for that resident and then turns around and bills a second resident for the rest of the supplies. Another way to use this scheme is buying a “kit” of supplies for a lower price and charging out each individual supply at higher charges.

Double Billing: One fraudulent scheme used by nursing homes is billing different government entities for the same charges.  For example, if the nursing home bills Medicare for equipment or supplies and still bills Medicaid a daily or per diem rate for providing services, the cost of equipment and supplies is included in the Medicaid rate.  Therefore, they are double billing.

If you suspect a nursing home has committed one of these fraudulent schemes or other fraud, then you may be eligible for a whistleblower reward.  However, to become eligible for such a reward, there are very specific steps that must be taken. You need to contact a skilled nursing home attorney to file a qui tam suit under the False Claims Act.  If you merely call and report this to the reporting hotline, you would not receive the reward.  The attorney must follow a precise procedure in order to get a potential reward for reporting Medicare or Medicaid fraud.  Call Wagner Hughes, LLC for a free consultation at (404) 900-6979 to see if your case may qualify.