Signature Healthcare is a national for-profit nursing home chain with more than two dozen facilities in Tennessee.  The government started an investigation in 2014 when two whistleblowers started collecting evidence on their own.  LeeAnn Holt and Kristi Emerson, both of whom are occupational therapists from Columbia, collected reams of anecdotes — in part, because they were concerned they might get in trouble themselves.  That evidence is the basis of the $30 million settlement in the Medicare fraud case between the federal government and Louisville-based Signature Healthcare, which operates more than 100 facilities in 17 states.

According to court documents, state and federal investigators discovered Signature was “knowingly submitting false claims to Medicare for rehabilitation therapy services that were not reasonable or necessary” at 115 of its facilities. Investigators said that led to a total of $232 million in false claims. The company also allegedly forged documents submitted to Tennessee’s Medicaid or Tenncare program, leading to another $12 million in fraudulent reimbursements.  So they stole $232 million but only had to pay a settlement of $30 million.  Who says crime doesn’t pay?

The complaint against Signature Healthcare (download here) accuses the company of systematically administering occupational, physical and speech therapy when it wasn’t warranted and withholding care when government reimbursements were already maxed out. According to the suit, the unnecessary therapy pushed patients into a category where the facility was reimbursed more per day for those patients, often hitting precisely the 720-minute per week threshold for maximum payment.  Holt and Kristi Emerson are the whistle-blowers who exposed a company-wide system of over-billing the federal government by Signature Healthcare.

“There were a couple of times when things happened with patients where we would just look at each other and say, ‘We can’t do this. We just cannot do this any more,'” LeeAnn Holt recalled.  Holt recalls a patient with advanced cancer who just wanted to spend time with her family rather than continue with therapy.

“She just put her hand on the therapist and said, ‘Honey, you need to go work with somebody that can really benefit from this.’ And you know, when you have a patient that is telling you that, you really have to stop and take inventory of what is going on here.”

Emerson says she hopes the case will still inspire other health care workers to push back when they feel pressured to do procedures they deem medically unnecessary.

“We can’t just blame these corporations for all of this,” she says. “We have to shoulder as therapists some of the responsibility because we’ve allowed this to get this bad.”

The women say before filing their suit, they repeatedly went to administrators all the way up to the corporate office.

“And no one was doing anything. And the more we reported, the more they came in and just started pushing back on us,” Emerson explained.

Emerson and Holt were let go amid the investigation and have found it difficult to find stable work. “No one really wants a whistleblower in their building,” Emerson says.

But now they will split roughly $6 million as their share of the settlement. Whistleblowers are entitled to 15 percent to 25 percent of the total.

 

New York Magazine had an article about Trump’s decision to withdraw protections from people with pre-existing conditions claiming their are “unconstitutional”.  Republicans kept versions of the Affordable Care Act’s protections for people with preexisting conditions in all of their health-care bills last year.  Now Trump and Sessions are attempting to take them away.

“Specifically, the Justice Department announced that it would not defend the Affordable Care Act from a challenge brought by a group of red states, which claims that Congress’s repeal of the individual mandate renders the rest of the law unconstitutional — as that provision is not severable from the rest. This is a legal claim so radical and ill-supported it made the National Review blush. The notion that Congress is not constitutionally allowed to eliminate the ACA’s insurance mandate — unless it also repeals the law’s other regulations of the health-care market — is not some sacred principle of constitutional originalists. Rather, it’s a transparently ad hoc rationalization for the judiciary to veto a duly-passed expansion of the safety net. And yet, Attorney General Jeff Sessions concluded that his department could make no honest argument against the plaintiffs’ case.”

“Out-of-pocket health-care costs are rising for virtually everyone in the United States. Drug prices are resolutely high, premiums on the individual market are skyrocketing (thanks to the GOP’s tireless efforts to sabotage said market), and the average deductible for those with employer-provided insurance has increased by nearly 400 percent since 2006. The Democratic Party’s prescription is for the government to impose price controls, while further subsidizing ordinary Americans’ health-care costs by raising taxes on the rich (the party is internally divided over the details of its policy, but united on its general direction). The Republican Party, by contrast, is beholden to reactionary interests who want the government to cut public spending on health care, so as to finance ever-lower taxes on the wealthy and corporations.”

 

The Republican budget includes a series of cuts to long-term health services. According to an analysis by the Congressional Budget Office, the new legislation reduces direct Medicare funding for nursing homes by $1.9 billion over 10 years – or $140 million starting in October.

Medicare delivers higher payouts, covers a broader range of costs and comes with more certainty. Even though Medicare patients have comparatively relatively short stays – they’re capped by law to 100 days – the overall revenue they bring in can stem the losses incurred by Medicaid patients.

 

Axios reported that “the pharmaceutical industry is livid about a surprise change to Medicare drug policy that was slipped into the Senate budget deal. The bill would close the Medicare Part D “donut hole” in 2019, a year earlier than previously scheduled, and force drug companies to shoulder most of the cost.”

 Medicare’s donut hole puts seniors and disabled people on the hook for a large chunk of their prescription costs. It’s supposed to go away in 2020, as part of the Affordable Care Act. Beneficiaries would pay no more than 25% of brand-name drug costs, while health plans would cover 25% and drug companies would cover the remaining 50% through discount payments.

But the Senate bill would end the coverage gap a year earlier, and change the ratios. Drug companies would be responsible for 70% of the costs instead of 50% — a move that would cost drug companies billions of dollars.

The Kokomo Tribune reported that two former owner/operators of nursing homes agreed to plead guilty in a kickback scheme involving millions of dollars.  American Senior Communities CEO James Burkhart and Chief Operating Officer Daniel Benson have reached plea agreements that could put them in prison for decades.

Burkhart and Benson were indicted in 2016 along with Burkhart’s friend, Steven Ganote, and Burkhart’s brother, Joshua Burkhart. Ganote and Joshua Burkhart also have reached plea deals.

Federal prosecutors who indicted the men on a total of 32 counts say they took part in a kickback scheme between January 2009 and September 2015 that netted them $16 million. Prosecutors said the men used shell companies to falsify and inflate costs of goods and services, which enabled them to steal discounts and rebates, and conceal kickbacks during the six-year period.

Prosecutors said the men used the money to buy lavish items, such as vacation homes, jewelry and gold bars.

The company manages nearly 100 senior care facilities, including 60 locations under a contract with Marion County’s public health agency. The county is home to Indianapolis.

In an article from the University of Missouri News Bureau, Sheena Rice details a new federal report which reduced hospitalizations and saved Medicare thousands of dollars per person. Read an excerpt below:

Researchers from the University of Missouri Sinclair School of Nursing are continuing to see success in their work to improve quality of care in nursing homes. In 2016, a federal report found that the Missouri Quality Initiative for Nursing Homes (MOQI) reduced potentially avoidable hospitalizations by 48 percent and reduced hospitalizations from all causes by 33 percent. This reduced total Medicare expenses by $1,376 per person, saving 33 percent of the costs of all-cause hospitalizations and 40 percent of potentially avoidable hospitalizations.

You can read the full report here.

The Clarion Ledger reported the $1.25 million settlement between U.S. Department of Justice and Hyperion for allegations of false Medicare and Medicaid claims for  “grossly substandard care” at a Lumberton nursing home.  The government alleges that from October 2005 to May 2012, Hyperion made claims to Medicare and Medicaid for providing effectively worthless services to the nursing home residents.  The poor quality care caused the facility’s residents to suffer pressure ulcers, falls, dehydration and malnutrition, among other physical, mental and emotional harms, the government says.

Hyperion Foundation, a Georgia not-for-profit entity (Hyperion), Julie Mittleider, Hyperion’s former president, AltaCare Corp., a Georgia corporation engaged in nursing home management, Douglas Mittleider, AltaCare’s chief executive officer,  Long Term Care Services Inc. and Sentry Healthcare Acquirors Inc., and others have agreed to pay the settlement for alleged substandard care to residents at the Oxford Health and Rehabilitation nursing home in Lumberton. The nursing home was operated from late 2005 through mid-2012 by AltaCare, under a contract with Hyperion.

For example, the United States alleges that Hyperion failed to meet the nutritional needs of residents, failed to administer medications to residents as prescribed by their physicians, over-medicated residents, hired insufficient staff to care for them and diverted Medicare and Medicaid funds to other entities affiliated with Douglas or Julie Mittleider, leaving the facility unable to pay for its basic operations, including food, heat, air conditioning, pest control and cleaning. 

“When operators of nursing homes harm our most vulnerable citizens and break the law by defrauding our government for grossly substandard or worthless services, we will bring to bear all the resources of the federal Government in order to rectify these terrible actions,” Southern District of Mississippi U.S. Attorney Mike Hurst said in the news release. “I commend our attorneys and investigators for resolving this travesty with one of the largest healthcare fraud settlements involving a single nursing home. We will continue the Department of Justice’s long-standing commitment to protecting the elderly.”

The lawsuit was filed under the qui tam provisions of the False Claims Act, which permit private parties to sue on behalf of the government for the submission of false claims and share in any recovery.  The False Claims Act authorizes the United States to intervene and take over primary responsibility for the action, as it did in this case.  The amount to be recovered by the private whistleblower has not been determined.

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.