Have you ever read a government enforcement action and wondered whether your own processes would withstand that level of scrutiny? Recent False Claims Act Allegations in Senior Living Communities serve as an important reminder of the need for ongoing oversight of the MDS and billing process.
Three affiliated skilled nursing communities in Illinois have agreed to resolve allegations that they violated the False Claims Act. The allegations involved submitting or causing the submission of false claims to the Centers for Medicare & Medicaid Services (CMS). According to the U.S. Department of Justice, the communities allegedly billed Medicare for medically unnecessary rehabilitation services. These services included physical therapy, occupational therapy, and speech pathology. The allegations also stated that services were provided without regard for residents’ individual medical needs. As a result, the communities allegedly submitted false claims based on inflated Resource Utilization Group (RUG) levels between January 1, 2014, and September 30, 2019. Additional details are available in the Department of Justice announcement regarding the settlement.
The allegations resolved by the settlement arose from a qui tam, or whistleblower, lawsuit filed by Integra Med Analytics. Under the False Claims Act, private parties can sue on behalf of the government. They may also receive a portion of any recovery. Cases like this show how billing practices and documentation can come under scrutiny. They also highlight the importance of demonstrating the medical necessity of services provided to residents.
Now that I have your attention, does your QAPI committee have an ongoing audit plan for overseeing the MDS and billing process? If not, it may be time to consider one. Outside providers can perform audits and compliance reviews. While these services can be expensive, they are often far less costly than a False Claims Act settlement. In addition, do your staff members and contracted service providers know how and when to report questionable activity? Consider reinforcing the importance of reporting anything that seems unusual at your next employee meeting. You may also want to bring this article to your next QAPI committee meeting. False Claims Act Allegations in Senior Living Communities remind us that ongoing monitoring, education, and accountability remain essential parts of an effective compliance program.
Stay well and stay informed!
