Medicare Fraud Skilled Nursing Facilities

Jeff represents a former Rehab Aid for a privately held rehabilitation company providing physical therapy, occupational therapy and speech therapy in nursing homes and assisted living facilities. Under the Social Security Act, such services are eligible for reimbursement only if they are medically necessary for the patient. The whistleblower observed from the company scheduled all patients to receive the highest levels of care or “Ultra-High” under Medicare terms, but that the scheduling of the services was unrelated to the patient medical needs but rather done solely for profits. Ultra High provided the highest levels of reimbursement for the company. The way Medicare determines what reimbursement is rendered is that there is a period called the ARD in which the amount of care is recorded and submitted. The whistleblower noted that directly after the Ultra High was determined during the ARD period, the company would ramp down the services in order to reduce labor burdens while still receiving the highest reimbursements from Medicare. This was company-wide. Some of the patients were very old and quite ill and when they were scheduled for rigorous daily schedules of therapy they could not tolerate the regimen and some became more ill. Despite this company managers required the therapies to continue. In addition, the whistleblower noted that the diagnosis codes recorded in the patient’s discharge reports were altered with a specially designated code for the company allowing for higher reimbursements. These were the codes ultimately used for Medicare billing purposes. This case is in litigation.

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