Blowing the Whistle on Nursing Homes Who Abuse Medicare, Medicaid, and TRICARE During the COVID-19 Pandemic

The frail elderly are some of the most vulnerable people in our society, even outside of the context of the COVID-19 pandemic. They are also an easy target for scammers. It’s so prevalent that the National Council on Aging calls scams targeting seniors “the crime of the 21st century,” and number one on that list is Medicare/Medicaid and other healthcare fraud.

When you think of the kind of person that would defraud the frail elderly, your mind may conjure up images of smooth talkers on the phone or shady people behind computer screens convincing a trusting senior to give up private information.

But what if the scammers, fraudsters, and thieves are some of the nursing home corporations who promise to care for them? And it’s not just our elders who are victims in this case. Medicare, Medicaid, and TRICARE (military healthcare benefits) are programs funded by taxpayer dollars, so you, me, the millions of taxpayers that give up a part of every paycheck towards taxes, and the U.S. government are all gravely affected by such dishonesty.

 

Potential Qui Tam Whistleblower Claims Against For-Profit Nursing Homes

About 69.3% of nursing homes in the U.S. are for-profit, according to the most recent study by the CDC. But during the COVID-19 pandemic, who is keeping track of the quality of care at nursing homes and making sure they are accountable for their Medicare, Medicaid, and TRICARE billings?

Who is making sure that the giant billion-dollar corporations that run for-profit nursing home chains are accurately and fairly charging the government for the services they tell the government they are spending on their residents?

You. The only person who may be able to hold fraudsters accountable in these cases may be you. If you work (or used to work) in a nursing home – whether you’re an administrator, someone who works in billing, a physical therapist, a nurse, etc. – who witnessed or knew about the corporation or its facilities misrepresenting the condition of patients under the old Resource Utilization Group (RUG) simply to extract more (taxpayer) money, we are here to partner with you to try to stop the fraud. We support those who choose to do the morally right thing and we work hard to try to ensure they get the proper and just compensation for their actions.

If your nursing home is involved with the kinds of bad behavior we discuss below, please call the NC Whistleblower Attorneys at 1-844-520-2889, chat with us, or send us a message here.

What Medicare, Medicaid, and TRICARE Fraud in Nursing Homes Could Look Like

Because of the COVID-19 (coronavirus) pandemic, regulatory agencies – and the government as a whole – have more things to keep an eye on, and they may have fewer people under employ. We will likely see an upsurge in nursing home-related lawsuits stemming from misconduct during this crisis in the next few months and years. And Medicare/Medicaid healthcare fraud will be at the forefront of common allegations.

Here are just a few of the ways such fraud could manifest, according to the National Whistleblower Center:

  • Billing Medicare and/or Medicaid for services not performed
  • Billing for services provided to ineligible persons
  • Defective or illegal pricing of drugs
  • Failure to comply with “best pricing” in the Medicaid program
  • Failure to properly enroll qualified patients in a Medicaid sponsored program
  • Nursing home abuses
  • Illegal or improper marketing of drugs
  • Overcharging at pharmacies
  • “Off label” marketing of drugs
  • Paying kickbacks to have doctors, hospitals or other care-givers prescribe certain drugs or otherwise bill the Medicare and/or Medicaid
  • Kickbacks to obtain business
  • Kickbacks to induce prescriptions
  • Performing unnecessary medical treatments
  • Improper referrals or self-dealing
  • Violations of various rules governing government procurement and contracting, such as the Stark Act, the Anti-Kickback Act and the Best Pricings laws
  • Knowingly presenting (or causing to be presented) to the federal government a false or fraudulent Medicare and/or Medicaid claim for payment
  • Knowingly using (or causing to be used) a false record or statement to get a Medicare or Medicaid claim paid by the federal government
  • Conspiring with others to get a false or fraudulent Medicare or Medicaid claim paid by the federal government
  • Knowingly using (or causing to be used) a false record or statement to conceal, avoid, or decrease an obligation to pay money or transmit property to the federal government
  • Knowingly presenting (or causing to be presented) to the federal government a false or fraudulent Medicare and/or Medicaid claim for payment
  • Knowingly using (or causing to be used) a false record or statement to get a Medicare of Medicaid claim paid by the federal government
  • Conspiring with others to get a false or fraudulent Medicare or Medicaid claim paid by the federal government
  • Knowingly using (or causing to be used) a false record or statement to conceal, avoid, or decrease an obligation to pay money or transmit property to the federal government

During the COVID-19 pandemic, other forms of fraud have surfaced.

According to one of our own experienced nursing home attorneys, Elizabeth C. Todd, “Family members are not allowed into the facilities to advocate for their loved ones. Regularly-scheduled inspections by the Division of Health Service Regulation are not occurring, so there is little to no oversight inside the facilities. The bad choices that some nursing homes in the industry have made over the past years are exacerbating the crisis facing many areas of health care in the state. And the choice by some nursing homes to drastically understaff its facilities has led to windfalls in profits in past years. Some nursing homes rake in significant profits from not having enough caretakers in the facility, but by telling Medicare and Medicaid that they do.

Moreover, there have been reports of nursing homes attempting to require residents to sign over their $1,200 economic impact payments. While this is not necessarily a qui tam claim, it’s one powerful example of the ways some nursing home corporations can make a greedy grab for money. The nursing homes claim that because the person is on Medicaid, the facility is entitled to the money. This is not true.

According to the CARES Act, the economic impact payment is a tax credit for the resident, not the nursing home! Under federal law, tax credits do not count as resources for federal programs like Medicaid. Any attempt by a facility to seize this money is unlawful. DO NOT let your nursing home take economic impact money from its residents.

A Case Study of the Saber Healthcare Holdings, LLC Qui Tam Settlement

Take for example the recent nursing home qui tam case against Saber Healthcare Holdings, LLC (“Saber”).

From 2013 to 2017, at their facilities in Ohio, Pennsylvania, North Carolina, and Virginia, Saber allegedly required directors and the therapists at their nursing home facilities to place all newly admitted residents in the “ultra high” group of the now-outdated Resource Utilization Group (RUG). As you may know, this was the category that brought the most Medicare reimbursement for nursing homes. This was directly contrary to the Medicare regulations that state that it covers only what is “reasonable and necessary for the diagnosis or treatment of illness or injury.”

The whistleblowers, or the “relators,” claimed that even if the residents did not need or could not tolerate the therapy at that level, they were still instructed by Saber to categorize residents at that level. Moreover, some of the therapy services they provided were unrelated to that individual’s medical needs.

Saber settled for $10 million, which means that they chose to pay that amount rather than have the federal government make any findings of liability. Therefore, the instances remain allegations.  The three whistleblowers who alerted the U.S. government of the wrongdoings will walk away with $1.75 million of that settlement, and Saber will be required to submit to reviews of their Medicare billings and transactions for the next five years.

Qui Tam Claim Basics

There are different kinds of laws that protect whistleblowers, depending on what kind of fraud is being perpetrated. For example, whistleblowers who report fraud involving stocks and securities will be protected by a different whistleblower law than one who reports unlawful environmental pollution in their company.

When there is fraudulent use of taxpayer/government money, a whistleblower claim is called a qui tam claim, and the law that protects whistleblowers in qui tam claims is called the False Claims Act, or the “FCA.” There are, of course, financial incentives to consider if a claim is successful.

The federal False Claims Act and North Carolina False Claims Act both impose treble (or triple) damages on culpable defendants. These are what would protect you and allow you to bring a qui tam claim against your nursing home.

With a federal nursing home fraud claim, you, the whistleblower, could receive anywhere from 15 to 25% of all money recovered by the government, if the government intervenes in the case and the case is successful.

With state nursing home fraud claims, a successful relation can receive up to 25% of any recovery if the Attorney General gets involved and the case is successful.

If the government doesn’t join your qui tam lawsuit and you proceed on your own with a lawyer, you could potentially receive 25 to 30% of the government’s recovery if your case succeeds.

How much you ultimately receive will depend on many factors, including:

  • The quality of the information you provided — the more detailed and extensive the information, the more your potential reward
  • How much assistance you provide in the case
  • Whether the case involves a significant public safety issue
  • And various other factors

NC Whistleblower Lawyers Are Here to Try to Keep Nursing Homes Accountable for Medicare, Medicaid, and TRICARE Fraud

These are trying times for all of us. We stand ready to help all potential whistleblowers who want to put an end to fraudulent practices, even those who may have some hesitations due to financial concerns. We want you to know that you will not be alone, and a potential successful claim can bring about great rewards. There is a statute of limitations time period in which one can successfully report fraudulent behavior, so please don’t wait to call us.

If you believe your nursing home is involved with Medicare, Medicaid, or TRICARE fraud, please call the NC Whistleblower Attorneys at 1-844-520-2889, chat with us, or send us a message here.

 

Prefer we contact you?(100% confidential)
Submission of any information to ncwhistleblowerattorneys.com does not constitute an attorney-client relationship. Our attorneys are licensed to practice law in North Carolina.