U.S. News had an interesting article discussing how Louisiana‘s payments to private nursing homes for taking care of Medicaid patients have risen substantially over the last decade increasing profits even as their occupancy rates stayed flat, according to an audit.  The state Medicaid program spent $8.7 billion in federal and state dollars on nursing home care for people who are elderly or disabled from 2006 through 2016, as daily rates paid to about 260 nursing homes increased 54 percent from $112.34 to $172.82.  In the last budget year that ended June 30, Medicaid payments to the facilities reached $1 billion.  Occupancy rates over the same period, however, “have generally remained the same,” growing by less than 1 percent.

One easy explanation is that the nursing home industry is powerful and a hefty campaign contributor at the state capitol.  In fact, inadequate monitoring and enforcement caused the department to fail to recoup $3.2 million in Medicaid payments for ineligible patients in 2014.

 “Even with the increasing payments to nursing facilities, Louisiana continues to rank poorly in regards to quality of care,” auditors wrote.
 Auditors also said the Louisiana Department of Health needs to improve its oversight of payments to ensure they’re accurate. They said the agency should issue penalties for late cost reports from nursing homes and tougher sanctions for facilities that have repeat audit violations.

The Department of Justice announced four San Diego-area nursing homes owned by Los Angeles-based Brius Management Co. have agreed to pay at least $6.9 million to resolve allegations that their employees paid kickbacks for patient referrals and submitted fraudulent bills to government health care programs. The four nursing homes involved in the settlement are: Point Loma Convalescent Hospital, Brighton Place – San Diego, Brighton Place – Spring Valley, and Amaya Springs Health Care Center in Spring Valley.  The settlement resolves an investigation into allegations that their employees paid kickbacks to discharge planners at Scripps Mercy Hospital San Diego to induce patient referrals to the nursing homes in violation of the federal Anti-Kickback Statute.

“Kickbacks for patient referrals are illegal under federal law because of the corrupting influence on our nation’s healthcare system,” said Acting United States Attorney Sandra R. Brown. “This settlement demonstrates our resolve to combat fraud that compromises the care provided to patients served by a government healthcare plan. This case further shows the power of whistleblowers to shine a light on corrupt activities and obtain significant recoveries on behalf of United States taxpayers.”

The investigation examined additional allegations made in a “whistleblower” lawsuit that the nursing homes submitted false claims to Medicare and Medi-Cal for services provided to patients referred from Scripps Mercy Hospital. Bills submitted for patients referred as a result of illegal kickbacks would constitute fraud against the United States and the State of California.

The settlement resolves a lawsuit brought by a former employee of one of the nursing homes under the qui tam – or whistleblower – provisions of the federal and state False Claims Acts, which allow private citizens to file lawsuits on behalf of the United States and California and share in any recovery. The whistleblower, Viki Bell-Manako, will receive 20 percent of each settlement payment. Pursuant to the settlement, United States District Judge John F. Walter today dismissed the lawsuit, United States of America, State of California ex rel. Bell-Manako v. Brius Management Co., et al., CV11-2036-JFW.

Nursing home employees conspired to pay kickbacks allegedly without the knowledge of Brius Management Co. The nursing homes admitted that their employees used corporate credit cards to pay for gift cards, massages, tickets to sporting events, and a cruise on the Inspiration Hornblower that were given to planners at Scripps Mercy Hospital as kickbacks.

“Skilled nursing facilities that pay kickbacks in order to boost profits will be held accountable for their improper conduct,” said Christian J. Schrank, Special Agent in Charge of the U.S. Department of Health and Human Services Office of Inspector General. “We will continue to crack down on kickback arrangements, which can corrupt medical decision-making and undermine the public’s trust in the health care system.”

 

 

The Clarion Ledger reported the settlement between the Department of Justice and a Georgia nursing home and its management company for “grossly substandard care”.  Hyperion Foundation, the owner, and AltaCare Corp., the management company, agreed to pay $1.25 million to resolve allegations of Medicare and Medicaid fraud for failing to provide care at Oxford Health and Rehabilitation nursing home.

The poor quality and lack of staff caused serious health issues including pressure ulcers, dehydration, malnutrition, and falls according to the government investigation.  I hope the DOJ continues to investigate the adequacy of the services provided to nursing home residents to increase quality and to rid the industry of the waste, fraud, and abuse that is so common.

 

 

 

KBTX reported that Health Services Management Inc. (HSM) has paid the United States $5 million to resolve claims that the company billed the Medicare and Medicaid programs for worthless services and for services that were never provided.  HSM is based in Murfreesboro, Tennessee, and owns and operates nursing homes throughout the United States.

The whistleblower worked at Huntsville Health Care Center, a 92-bed nursing home and rehabilitation facility that HSM owned and operated.  She claimed that during her employment, she witnessed patient abuse and neglect, inadequate care, physical and verbal abuse and denial of basic services, such as providing patients with food and water.

The investigation concluded that from Jan. 1, 2013, through Dec. 31, 2015, Huntsville Health Care Center billed for services that were not provided or which were so substandard and deficient that they were considered worthless and potentially harmful to specific Huntsville patients.

“We take seriously the care of our most vulnerable citizens, the elderly and infirm,” said Martinez. “When providers accept federal funds for reimbursement, they have a duty and responsibility to provide the best care possible to the patient, especially when those patients are elderly and at times incapacitated. The United States Attorney’s Office (USAO) for the Southern District of Texas will aggressively hold those accountable who fail to provide the care that is expected when the failure to do so results in harm to the patients and the treasury.”

“It’s disturbing when a nursing home company accepts Medicare and Medicaid money to care for vulnerable nursing home residents and in return provides substandard care, as alleged in this case,” said Special Agent in Charge C.J. Porter of the U.S. Department of Health and Human Services – Office of Inspector General (DHHS-OIG). “We will continue to hold nursing homes accountable to give residents the quality health services, and living conditions, taxpayers pay them to provide.”

The Santa Fe New Mexican reported that Casa Real nursing home in Santa Fe owned and operated by Preferred Care Partners Management Group has at least temporarily improved persistent quality-of-care problems enough to resume billing Medicare and Medicaid for newly admitted residents.  Casa Real is one of only two homes in Santa Fe that accept Medicare and Medicaid patients.

For more than two months, Casa Real had been barred from charging Medicare or Medicaid for new residents after the Centers for Medicare and Medicaid Services found the nursing home wasn’t in compliance with federal care standards.

Inspections this year turned up a long list of problems, including medication errors, expired food and drugs on shelves, unreported resident injuries and assault, poor care of bed sores, nursing understaffing and inadequate safeguards against the spread of dangerous infections.

The former director of nursing at Casa Real from May to August has accused management of forging patient records in an attempt to show the facility was in compliance with care standards dealing with monitoring of medication effects on residents.  Of course, she was soon fired.

The August inspection found residents weren’t receiving medications as directed by their physicians and that the nursing home wasn’t doing enough to ensure that residents didn’t receive unnecessary drugs, including psychotropic medications.

The federal agency in May designated Casa Real as a “special focus facility” because of its poor record of complying with care standards, and it said the nursing home would be subject to more frequent inspections. The designation is given to the nation’s poorest-performing nursing homes and is meant to address the “yo-yo” problem of facilities routinely falling in and out of compliance with care standards.

The state Attorney General’s Office is suing Preferred Care, alleging it has defrauded Medicaid by having insufficient staff to meet the needs of residents at its Santa Fe nursing homes, as well as its facilities in five other New Mexico communities. Preferred Care has denied the allegations.

The Hill had an article on the False Claims Act.  The FCA authorizes private individuals to sue anyone they think is defrauding the federal government. Individuals filed more than 4,700 FCA actions between 2009 and June 2016. The Act provides for treble damages. The spoils are divided among the person alleging the fraud, his attorneys, and the federal government. In 2014, the Department of Justice reported that FCA “recoveries” totaled $5.79 billion. Health care lawsuits accounted for $2.3 billion of that.

The federal government must investigate the claims in every FCA case. The initial investigation is done under seal. Defendants may be investigated for years, but not know about it until their business documents are subpoenaed. The individual alleging fraud can proceed with a case even if the government decides against it.

Increasingly sophisticated groups of attorneys choose to continue. They sue any entity that receives federal payments, claiming that the failure to comply with administrative standards constitutes fraud. At the time the act was passed, the goal was to prosecute fraud cases in which a contractor billed the United States for nonexistent or worthless goods or services.

 

McKnight’s reported that Aggeus Healthcare CEO James Sayadzal pleaded guilty last year to a conspiracy charge and sentenced in federal court to 366 days in prison and ordered to repay $1.77 million to Medicare.  He was one of three company officers and six doctors who defrauded Medicare related to podiatry services provided to residents of nursing homes and long-term care facilities.

Prosecutors say they carried out a broad scheme from 2009-2015 by creating an electronic medical billing system that would lead Medicare to pay for procedures that weren’t performed or wouldn’t have been covered.  Nursing homes were told that Aggeus podiatrists would treat every resident for no cost to the facility. Some Aggeus doctors then performed unnecessary procedures or billed for procedures that weren’t performed, at Gray’s urging, charging documents say.

 Aggeus owner Yev Gray was sentenced Aug. 15 to 7½ years in prison and ordered to repay $6.97 million on charges of conspiracy and making a false statement relating to health care.

Gray’s wife, Natalie Gray was sentenced in February to 366 days in prison on the conspiracy charge and ordered to repay nearly $1 million. Natalie Gray was former director of corporate and legal affairs for the company.

Aggeus once had offices in 16 states and provided podiatry and other services to thousands of patients.  Podiatrists and nursing homes had complained about inaccurate medical notes or potential fraud.

Politico had an interesting article on the history of Medicaid and how Republicans choose to sabotage it.

In May 1965, Lyndon Johnson signed Medicaid into law–an afterthought tacked onto the administration’s Medicare bill, and one that LBJ scarcely mentioned when he signed both measures into law. Medicaid’s roots were humble, its ambitions modest. As originally conceived, the program provided health insurance to poor children, poor pregnant women and some qualifying parents. In its first year, its budget was less than $1 billion—about $7.7 billion in today’s dollars.  Medicare and Medicaid were quintessential Great Society programs: limited in ambition in scope and designed to help groups of citizens who could not, by virtue of their age or condition, capture the advantages of prosperity.

Over 50 years, successive Congresses and presidential administrations vastly expanded the program’s scope to cover 80 million people, or almost one-quarter of the populationIts budget last year was $378 billion. Medicaid enjoyed broad backing from Republican leaders.  The Social Security Amendments of 1965—the official name of the bill that established both programs—passed Congress with bipartisan support. In the House, 65 Republicans supported the legislation; 73 GOP members opposed it. In the Senate, Republicans voted 13 to 14 in favor of the bill.

With strong bipartisan support, Nixon extended the program to include disabled adults who qualified for Supplementary Security Income and allowed states to care for those in need of psychiatric care or suffering mental disabilities.

With overwhelming bipartisan support in Congress, Reagan expanded Medicaid by sharply raising the income eligibility level for women and children, created new categories of mandatory or optional coverage, and made it easier for people who lost eligibility because of rising incomes to remain in the program during a transition period.

Republicans didn’t set their sights on Medicaid until the mid-1990s, when Newt Gingrich’s conservative revolution turned the party’s caucus to the hard right.

Now, Republicans have proposed cuts to Medicaid which will leave many millions of poor people uninsured.  For 50 years, Medicaid proved a highly elastic Band-Aid for many of America’s economic wounds.  Over two-thirds of its spending benefits children, the elderly, or the blind and disabled. It covers costs for 64 percent of seniors in nursing homes and almost half of all births. It keeps afloat hundreds of rural hospitals, whose clients are disproportionately poor and elderly.  Its desecration will leave us in an unfamiliar and dangerous place.

TrumpCare isn’t an attempt to insure more people—or the same number of people—with greater efficiency or better outcomes. It throws people off insurance to pay for tax cuts benefiting the wealthiest Americans, as Republican skeptics like Maine Sen. Susan Collins have noted.

You and I have been dreaming of this since I have been around, since you and I were drinking at a keg,” House Speaker Paul Ryan told Rich Lowry, editor of National Review. The GOP’s full metamorphosis from the Party of Ronald Reagan to the Party of Ayn Rand is complete.

Some of its leaders can’t even get their heads around the idea of insurance—the means by which people mitigate risk, together. In the year 2017, GOP members of Congress honestly wonder aloud why men should be compelled to buy into plans that cover prenatal services. Shared risk and shared reward: It’s a concept so simple—so fundamental to living in a society—that they teach it in preschool. It’s why women who have children pay into insurance plans that also benefit men who develop testicular cancer. But today’s Republican Party has grown radically anti-social in outlook.

Medicaid was designed, and by increments expanded, to help certain disadvantaged groups: struggling single parents and their children, disabled workers, impoverished older people not yet eligible for Medicare, the underemployed, the working poor. But 50 years ago, no one expected the number of people in these categories to total one-quarter of the nation. It is a testament to the program’s elasticity that it has been able to paper over the inequities of the modern American economy for so long.

The Miami Herald reported the criminal charges of bribery against Bertha Blanco, a Florida health care administrator in exchange for helping a nursing home owner accused of orchestrating a $1 billion Medicare and Medicaid fraud scheme keep his license.  The wide-ranging investigation that federal authorities are calling the nation’s biggest health fraud case.

Blanco made about $31,300 a year overseeing inspections at nursing facilities owned by Philip Esformes, a wealthy businessman who owns dozens of Miami-Dade nursing facilities as well as homes in Miami, Los Angeles and Chicago.

A criminal complaint filed against Blanco accused her of taking tens of thousands of dollars in cash in exchange for tipping Esformes off about violations so he could address them before state inspections.  Blanco’s aid allowed Esformes to keep his license active and continue billing the federal government for questionable patient services.

Federal authorities say Blanco took the bribes and provided patient and inspection records to intermediaries, who delivered the information to Esformes.  Two of those intermediaries, brothers Gabriel and Guillermo Delgado, have made plea deals and are expected to testify against Esformes. The brothers helped investigators get to Esformes by videotaping a cash transaction that prosecutors said was meant to go for bribes.

Esformes is accused of using his 20 nursing facilities to file false Medicare and Medicaid claims for services that were not necessary for 14,000 patients.

Prosecutors said his health care network and other co-conspirators billed $1 billion for fraudulent services between 2009 and 2016.

CNN Money reported the great news for Ohio residents.  Health insurers in Ohio have agreed to sell Obamacare policies in 19 of the 20 counties that had no options for 2018, the state Department of Insurance said.  Roughly 11,000 Ohio residents in these counties currently purchase coverage on the exchange.

“The exchange markets are proving to be more resilient than many would have expected,” said Cynthia Cox, an associate director at the Kaiser Family Foundation. “Premium subsidies protect consumers from paying higher prices and may also make it possible for insurers to stay in counties that are otherwise unattractive.”

Trump is threatening to end insurance subsidies for low income people which will destabilize the market and prompt insurers to exit.  Hopefully, Trump will not intentionally sabotage the market.

Insurers have until late September to commit to participating on the exchanges for next year. That’s when they sign contracts with the federal government.