Fraud within Long-Term Care and Assisted Living Facilities is a serious issue. It’s important to be aware of the various forms of fraud that can occur in these settings in order to protect residents, their families, and the taxpayers funding Medicare programs.
Through education and awareness, you can help prevent long-term care fraud and ensure that patients are receiving the best care possible.
Let’s dive into some common long-term care fraud schemes and what to look out for.
Common Long-Term Care Fraud Schemes
Here are some common schemes used in assisted living fraud and nursing home fraud, and a few recent examples of organizations that have been accused.
- Medicare Switching
This type of fraud involves switching patients without consent or the ability to consent from Medicare Part C “Managed Medicare” to Medicare Part B “Traditional Medicare” purely for financial gain.
A recent example of Medicare switching occurred in 2022 when the Department of Justice announced a $7.85 Million settlement with Citadel Consulting Group. Citadel was accused of fraudulently switching healthcare coverage to boost Medicare payments, without resident consent. The actions of Citadel impacted residents’ out-of-pocket payments, the scope of the services and care covered, and their drug coverage plan.
- Contracted Rehabilitation
Fraud can occur when contracted rehabilitation companies qualify residents for rehab therapy (physical and occupational therapies) at a level of care that is not medically necessary, in order to increase billing revenues.
In 2021, the contract rehabilitation therapy provider Select Medical Corporation and Encore GC Acquisition LLL agreed to pay $8.4 million to resolve allegations that it violated the False Claims Act (FCA) by knowingly causing 12 skilled nursing facilities (SNFs) in New York and New Jersey to submit false claims to Medicare for services that were not reasonable, necessary, or skilled.
- Misreporting Expenses on the UB-92 Form
The UB-92 is a yearly cost report form used to submit expenses and/or costs reimbursed by the state. Fraud can occur when nursing homes or assisted living facilities submit claims with expense data that has been intentionally manipulated in order to increase their expenses to the state.
Any discount on invoices received by a facility must be reported to the Federal Government, similar to the Federal Drug Rebate Program. If they are not, the facility could be committing fraud.
For example, in 2015, AstraZeneca and Cephalon agreed to pay $46.5 million and $7.5 million (respectively) to resolve allegations that they knowingly underpaid rebates owed under the Medicaid Drug Rebate Program.
The Whistleblowing Process
If you work in a skilled nursing or assisted living facility and suspect fraud is occurring, don’t worry–you’re not alone. You can partner with our law firm to help shed light on the scheme.
Your information will be kept confidential and a lawyer will be there every step of the way to guide you.
If you do step forward, here are a few steps you can expect:
- Get Expert Guidance. Let us know what you’re experiencing by scheduling a confidential and no-obligation meeting. We’ll help determine what kind of fraud may be occurring and any violations we may suspect.
- Gather Information & Evidence. To help corroborate your story, it’s best to gather any documents, emails, or recordings you may have that demonstrate the suspected fraud has occurred.
- File a Claim. A whistleblower must file a qui tam complaint in court and submit it to the government, along with a Disclosure Statement that details the alleged fraud. Our law firm will assist you in submitting all paperwork necessary for filing your report.
- Investigation. The government will examine your evidence, review your documents and may also request additional documents relating to the alleged fraud. During this time, your experienced whistleblower attorney will be by your side to make sure you provide whatever information the government requests. Your attorney will also be there to remind you not to discuss your case with anyone while it’s under seal.
- Stay Vigilant & Safe. After the government investigates, it will decide whether it wants to bring formal legal action against the accused. If the government does decide to intervene and take over the prosecution, the case will then proceed through the process of litigation or settlement.
- Earn a Significant Reward. Whistleblowers who bring original information to the government can be entitled to receive a share of the government’s recovery. An individual (called a false claims plaintiff or relator) who is an original source of information can sue for violations of the False Claims Act. If the government prosecutes, a relator can receive up to 25% of the total amount recovered.
Throughout the entire whistleblowing process, Daniel J. Ocasio Whistleblower Law Group (DJO) will advocate for your rights and provide counsel for navigating the arduous but rewarding process of shedding light on fraud.
Exposing Nursing Home Fraud
Our goal at DJO Whistleblower Law Group is to expose nursing home fraud wherever and whenever possible. We work with individuals in a range of healthcare settings to gain information, build a case, and fight for justice on behalf of patients and taxpayers. In doing so, we can protect those affected by long-term care fraud and make the world a safer place.
If you suspect fraud in your organization, please contact us. DJO is comprised of a highly experienced team of whistleblower experts, lawyers, and even former whistleblowers, who strive to deliver the highest monetary reward for brave individuals who have valuable information that can expose fraud.
If a whistleblower’s lawsuit is successful, the reward can be up to 25% of the funds recovered. The False Claims Act also offers whistleblowers protection against job retaliation or wrongful termination.
Do you have valuable information that can help bring health care fraud to light? Speak to our experts today.
authored by Christopher J. Piacentile
Director of Investigations DJO Whistleblower Law Group
