Category Archives: Medicare

The website Skillednursing had a conversation with a nursing home therapist about the new reimbursement model Patient-Driven Payment Model (PDPM). The early takeaway from PDPM is the effect of therapists who work at skilled nursing facilities.

Almost instantly after the PDPM shift on October 1, Skilled Nursing News received a flurry of e-mails from therapists who were laid off or saw their hours reduced as providers adapted to the new system — which bases reimbursements on resident acuity, and not the volume of services provided.

The federal government framed the shift as a way to reduce the unnecessary provision of therapy minutes for financial gain, which officials asserted was all too prevalent under the previous Resource Utilization Group (RUG) system. But experts, consumer advocates, and therapists claim that operators are cutting therapy services to the detriment of resident outcomes.

One of the therapists who sent in concerns to SNN’s inbox agreed to take part in our regular Confessions series, a Q&A feature that offers players in the post-acute and long-term care space an anonymous platform to express their opinions.

Tell me about your experience with the PDPM shift.

I’ve worked mainly the past 10 years in nursing homes — primarily the same nursing home, basically. But in 10 years, even though I’ve been in the same nursing home, one, two, three, four different employers have come and taken over the therapy. I think that seems to be common with with therapy departments —they lose contracts with national companies, or they go in-house, and it just switches around.

There’s always changes with Medicare; over the past 10 years, there’s been Medicare changes, but it’s been sort of a gradual decline. We haven’t had a pay raise since 2011.

The company has changed, like I said, four different times. So there’s been a deterioration — you’re not going to get a raise, but we still want you to do more. And then there’s obviously been some big changes — PDPM, and there’s probably more to come.

People have been laid off as the companies changed. People have lost their jobs — like a few here, and then a few in the next round of changes, and then I lost my job with PDPM.

How many other people lost their jobs, or had their status change?

I think it was just me this time. When we changed, some people left on their own, and with PDPM, we had one person elect to leave because PDPM also coincided with the change of company again. It was kind of: Two things happened at the same time. This all happened the beginning of October.

Walk me through how your bosses conducted the PDPM transition from your perspective — over the last 18 months, a lot of leaders told me about their plans for the change, but what did it functionally look like on the ground?

From my perspective, we started 2019 with the big national company, and they were preparing us with webinars, and then they’d do teleconferences. [It was] mandatory — everyone would sit around the phone and listen on about what changes they were going to make.

But then, in the springtime, that’s when we went in-house. And once we went in-house, they didn’t prepare us. They just didn’t have any in-services for us, or tell us anything about it. And then I guess it was around October when we were no longer in-house; another company took us over, a smaller company. At that point, they just told us to do group.

And then they also said to do concurrent. This has been the main push, that you have to do groups, and they want you to do concurrent. We used to do that 10 years ago — we were doing that, and then we were told not to do it, and now we’re being told to do it again.

What sort of justification is being given for these shifts? In theory, PDPM is supposed to allow therapists to tailor their services more closely to residents’ needs, but I have heard anecdotal stories about therapists being told to hit certain thresholds.

It seems to be that we just need to do it and we’re not told why. Ten years ago, we did groups because we just had a lot of patients. We didn’t have a lot of therapists, and I suppose it was an economic factor.

We do groups in rehab, because the focus is more that it’s socialization, and you’re going to have a topic, and it’s very well planned — whereas skilled nursing has always been difficult. You can’t always schedule your day; it’s hard to schedule a group sometimes, because people don’t want to do it all, you know, at 11 o’clock. They’re not ready.

It’s just now we don’t have as much time to schedule our patients as you do in acute rehab.

From your standpoint, do you think PDPM will achieve the goals that the government has laid out for it? For me, it’s hard to reconcile the two main opposing forces: the government saying the old system encouraged fraud, and the many therapists reaching out to me saying the new system is just making it worse in different ways.

I agree that the RUG system was just taking minutes. Fortunately, the facility I’ve been in the past 10 years, we didn’t keep people 100 days just to keep them. I mean, there was pressure, if it was the last day of their ARD and they couldn’t get their minutes, you might be asked to go back because they would lose out on money that they’d been working on for weeks up until that point. There was pressure like that.

But PDPM should be a good thing because they’re running out of money, and we don’t want to be giving services [that people don’t need]. And I know there are nursing homes that just keep people 100 days and give them lots of minutes of therapy when it’s not appropriate.

So I think it’s a good thing, but my concern is that because the money is running out, it’s our problem. It becomes our professional problem, because I think nurses are getting raises — and they’re working within the Medicare system. And the CNA is getting a raise. But because therapy is not making money, we get directly affected in our salary. There’s less emphasis on in-servicing about patient care, and more in-servicing about which code to use — and telling us that we need to do more of the administrative [work].

We don’t have a rehab tech, so we have to scan our documents and do all this extra [work] because they don’t have money, I guess, to pay for a tech to help us to transport or to do these things. We used to have a tech — 10 years ago, we had two of them.

So yeah, I think PDPM is good, but it’s bad how the companies are reacting — and they just take everything out on us. I don’t think they’ve had a pay cut, whoever is the director of the companies, or the director of the nursing home; they’re getting a cost-of-living increase, or they’re probably getting a raise, but we’re not.

It’s all the small little things that make you feel like you just are being erased, and you’re not valuable to them because you’re not making money anymore.

In the wake of the change, there’s been a sort of feeling that layoffs were inevitable, or that companies should have cut even more jobs just based on the math — but even more so than in other industries, you are dealing with people’s lives.

I’ve worked in health care enough to know that you have to change. They’re always changing their focus in rehab to where the money might be.

Twenty years ago, I was in acute rehab, and they all of a sudden started a vent unit because I think it was going to be something they could get money from. The focus wasn’t: “Oh, we have a lot of people on ventilators that need to be weaned.”

Maybe I’m cynical, but it has to be driven by: “Can we make money off this type of care?”

Is there anything else that you want leaders in the space to understand about your experience and the state of therapy today?

Residents and family are seemingly unaware of the changes. They don’t seem to know that they’re in a group because there’s been changes to Medicare and their length of stay is going to be shorter.

If the executives have any plans of educating Medicare recipients and family so they don’t expect their mom to get, you know, an hour of therapy — they might get 30 minutes — not to make big promises anymore about therapy, because we’re stretched too thin.

The Louisiana Department of Health has agreed to resolve allegations that it submitted false and inflated Medicaid claims for long-term nursing home and hospice care, the Department of Justice announced.  Under the settlement agreement, the state agency has agreed to pay $13,422,550. 

“Today’s settlement demonstrates that we will take whatever steps are appropriate in our effort to protect federal healthcare programs, including Medicaid, from false claims,” said Assistant Attorney General Jody Hunt for the Department of Justice’s Civil Division.  “Anyone who seeks to profit at the expense of Federal taxpayers, including state agencies, will face appropriate consequences.”

“This office will remain vigilant in its efforts to ensure the integrity of the Medicaid program by continuing to pursue those who commit improprieties against the program – whether they be providers or beneficiaries, or those more central to the administration of the program,” said Brandon J. Fremin, the U.S. Attorney for the Middle District of Louisiana.  “The people of Louisiana deserve it.  I am grateful to the dedicated AUSAs and staff in our Civil Division and to the Office of Inspector General for the U.S. Department of Health and Human Services for their hard work and dedication to this very important matter.”

Medicaid is a joint federal and state program providing financial assistance to individuals with low incomes to enable them to receive medical care.  The Medicaid program makes quarterly grant awards to each participating state covering an amount, commonly known as the federal share, of the state’s expenditures for healthcare services covered by the state’s Medicaid plan.  The federal share is determined by a percentage rate that is subject to change from quarter to quarter.  Nursing homes and hospices typically submitted claims to Louisiana on the tenth day of the month following the month during which the services were actually provided.  Louisiana then paid these claims, sought Federal reimbursement for those expenditures, and received Federal reimbursement based on the rate in effect at that time.

The United States alleged that the Louisiana Department of Health knew that the rates determining the federal share of Louisiana’s Medicaid payments were set to decrease following the months of December 2010, March 2011, June 2011, and September 2013.  To receive the higher Federal share percentage rates in effect during these months, the Louisiana Department of Health fraudulently caused its healthcare contractor, Molina Medical Solutions, to prepare, submit, and pay claims for nursing home and hospice services in these months, before the providers had submitted to Louisiana any claims for them.  Louisiana then claimed Federal reimbursement for those premature payments.  As a result, the Louisiana Department of Health received a Federal share based upon the higher percentage rate in effect in those months, rather than the lower percentage rate in effect the following months when the providers actually submitted their claims to Louisiana.

This settlement was the result of an investigation by the Civil Division of the Department of Justice, the U.S. Attorney’s Office for the Middle District of Louisiana, and the U.S. Department of Health and Human Services Office of Inspector General.

The claims resolved by this settlement are allegations only, and there has been no determination of liability.

McKnight’s reported that the Medicare system is spending “significantly” more money on post-acute care for patients when compared to those who have commercial insurance, despite it not being clinically more beneficial, a new study has found. The study was published in the September issue of Health Affairs and funded by the National Institute on Aging.

Researchers discovered that despite the difference in spending there were no significant differences in hospital readmission rates between the groups.

“When we looked at just the length of stay of SNFs (skilled nursing facilities) while comparing patients, (we found) longer average length of stay for Medicare patients,” Scott Regenbogen, an associate professor of surgery at the University of Michigan, told McKnight’s. “There may be clinically unwarranted longer lengths of stay among Medicare beneficiaries.”

Researchers used data from more than 25,000 patients throughout the state for the study. They then used a regression discontinuity design to compare post-acute care use and costs between seniors in their 60s who have traditional Medicare coverage or private insurance. They also focused on post-acute care received at skilled nursing facilities, at home and at inpatient and outpatient rehabilitation facilities.

Based on the findings, Regenbogen suggested post-acute care providers may want to be “really judicious with the volume of services they provide and conclusive of which of the post-acute care services are translating to better post-hospital outcomes.”


NBC News recently reported on Operation Brace Yourself.  The federal investigation discovered that medical brace manufacturers were allegedly paying kickbacks and bribes to doctors working with fraudulent telemedicine companies in exchange for Medicare patient referrals for medically unnecessary braces.

At least, two dozen people, including doctors and owners of medical equipment companies, were charged in a more than $1 billion Medicare scam. As many as 130 medical equipment companies were implicated in the scam that resulted in a total of $1.2 billion in losses, prosecutors said.  As part of the scheme, doctors profited by prescribing braces to patients they had little to no relationship with. Prescriptions frequently came after doctors had brief conversations via phone or video conference with patients they had never met, prosecutors said.

Investigators uncovered the sprawling plot that targeted elderly and disabled people by setting them up with back, neck and knee braces that they didn’t need, according to federal prosecutors.  The ill-gotten gains were then laundered through shell companies and used to buy exotic cars, yachts and luxury real estate in the United States and overseas, prosecutors said.

The taxpayers should be outraged by this,” Gary Cantrell, who oversees fraud investigations for the Health and Human Services inspector general’s office, said in an interview with NBC News. “These are losses to the Medicare program that we all, as taxpayers, fund.”

“White-collar crime is not victimless,” Sherri Lydon, U.S. attorney for the district of South Carolina, where the probe originated, said at a press conference announcing the indictments. “All taxpayers will endure the rising cost of health care premiums and out-of-pocket costs as a result of fraud on our Medicare system.”

KFGO had a great article about a recent study in JAMA Internal Medicine which indicated that nursing homes often discharge Medicare patients before daily co-payments kick in which suggests that nursing homes send some patients home for financial reasons before they’re medically ready to leave.

“Medicare pays for 100% of postacute care provided by skilled nursing facilities (SNFs) during the first 20 days within a benefit period. However, on the 21st day, most patients become responsible for a daily copayment of more than $150.1 This copayment may present a significant financial burden for some patients—particularly those with limited economic means—and motivate them to discharge from SNFs on the 20th day of care based on their financial resources rather than their recovery status. Skilled nursing facilities may also prematurely discharge some patients to avoid the risk of accruing bad debt from partially uncompensated postacute care. However, it is not known whether patterns of SNF discharge are associated with this change in Medicare payment responsibility on day 20.”

To see how the start of co-payments might impact discharge timing, researchers examined data on more than 4.5million skilled nursing facility discharges from January 2012 through November 2016.

Overall, a total of 220,037 patients were discharged on day 20, more than the 131,558 sent home on day 19 and the 121,339 released on day 21. Compared to patients discharged on days 19 or 21, those sent home on day 21 were more likely to suffer from multiple chronic medical conditions, live in poor neighborhoods, and be racial or ethnic minorities, the study found.

“Our results suggest that skilled nursing facilities are more likely to discharge economically vulnerable patients right before their copay kicks in,” lead study author Dr. Paula Chatterjee of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia said by email.

On day 20, for example, 12.5 percent of patients discharged were black or Hispanic, compared with 8.2 percent one day earlier and 7.5 percent one day later, the study found.

And on day 20, 15.2 percent of patients discharged were living in poverty and 7.7 percent were unemployed. These economically vulnerable patients represented a smaller proportion of those discharged one day earlier or later.

On day 20, however, 42.2 percent of discharges were patients with at least five different chronic health problems, compared with 39.9 percent on day 19 and 40.6 percent on day 21.

At the same time, patients more likely to be discharged on day 20 tended to fit the profile of patients who have had higher rates of hospital use and repeat hospitalizations in other studies, said Dr. Jennifer Goldstein of the Christiana Care Health and Sidney Kimmel Medical College in Philadelphia.

Those characteristics include male sex, African American race, Hispanic ethnicity, low-income demographics and a high burden of disease,” Goldstein, who wasn’t involved in the study, said by email.

The results “raise concerns that patients are forgoing needed medical care because of ability to pay, and/or that skilled nursing facilities are selectively discharging such patients out of concern patients will not be able to afford the copay,” said Dr. Ann Sheehy of the University of Wisconsin School of Medicine and Public Health in Madison.

“If financial reasons, as opposed to medical readiness, drive skilled nursing facility discharge, this could negatively impact health and safety for the most vulnerable Medicare beneficiaries,” Sheehy, who wasn’t involved in the study, said by email.

Roughly 36% of skilled nursing facilities saw a drop in their overall star ratings after planned fixes to the Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Compare system took effect last month. About 16% of providers gained at least one star under the ratings overhaul.  Approximately 47% of skilled nursing facilities had no change in their overall rating, but slightly more lost one or more stars on the quality measure, Martin told SNN.

Roughly 48% of providers lost one or more stars in the quality domain, and that’s largely driving the decrease in overall stars.  A building’s five-star score consists of three separate metrics, each of which CMS also ranks from one to five: survey, quality, and staffing.

Staffing had taken center stage in CMS’s ratings overhaul, particularly after a New York Times investigation last summer revealed that operators may have been less than accurate in reporting nurse coverage information. Federal officials responded by slapping 1,400 facilities with one-star ratings on staffing.

Both the staffing measure and the survey measure are important, with survey having the most weight. Still, practically speaking, providers receive one standard survey a year. And improving staffing will require extra funds coming in from somewhere, as well as the effort of finding competent employees in a major workforce crunch.  Improving a SNF’s quality metrics, however, can begin much more quickly.

SNFs can also take steps to improve how they keep track of patients when they are discharged. Readmission penalties are assessed 30 days after hospital discharge, and so SNFs could be on the hook for any complications that arise after a patient leaves their care.


A federal jury convicted Philip Esformes, the infamous owner of assisted living facilities and skilled nursing facilities in Florida, of a billion dollar healthcare fraud.  Esformes is guilty of making $1.3 billion in fraudulent claims to Medicare and Medicaid for services that were not provided, weren’t medically necessary or were received through kickbacks. Evidence showed he bribed physicians to admit patients into his facilities and paid off a Florida state regulator for notification of planned inspections.

Esformes was convicted of 20 counts — one of conspiracy to defraud the United States, two of receipt of kickbacks in connection with a federal health care program, four of payment of kickbacks in connection with a federal healthcare program, one of conspiracy to commit money laundering, nine of money laundering, two of conspiracy to commit federal program bribery and one of obstruction of justice.

“Even beyond the vital dollars lost … Esformes exploited and victimized patients by providing inadequate medical care and poor conditions in his nursing homes,” Shimon Richmond, special agent in charge of the U.S. Department of Health and Human Services Office of Inspector General’s Miami Regional Office, said in a statement. “We will continue the fight against such parasites.”

He personally benefited from the fraud and received in excess of $37 million. Esformes’ conspiracy involved a network of 16 assisted living facilities and skilled nursing facilities that he owned in Miami-Dade County.

Prosecutors said for 18 years–from January 1998 through July 2016– he cycled patients through his facilities in poor condition, where they received inadequate or unnecessary treatment, then improperly billed Medicare and Medicaid.

Extravagant purchases included luxury automobiles and a $360,000 watch, the Justice Department said. Prosecutors said he bribed the basketball coach at the University of Pennsylvania in exchange for his assistance in gaining admission for his son into the university. That coach, Jerome Allen, testified Esformes paid him about $300,000 in cash bribes and wire transfers.

A 12-person jury deliberated for four days before agreeing that the 50-year-old entrepreneur was guilty on 20 out of 26 charges. Those include paying and receiving kickbacks, money laundering and conspiracy to commit federal program bribery. Jurors did not, however, reach a verdict on the main count — that Esformes conspired to defraud Medicare.  Prosecutors blasted Esformes following the conclusion of the eight-week trial for the $1.3 billion scheme to defraud both Medicare and Medicaid, calling him a “despicable,” “vampire” who was fueled by “unbounded greed.”

Meanwhile, the government alleged, Esformes provided access to assisted living residents “for any healthcare provider willing to pay a kickback” — including pharmacies, home health agencies, physician groups, therapy companies, partial hospitalization programs, laboratories and diagnostic companies — even though many of the services for which they were paid were not medically necessary or were never provided.

Esformes plans to appeal according to defense attorney Roy Black, said the Associated Press, which also reported that Black suggested that prosecutors may have overstated the amount of money involved in the case.  Esformes, 50, originally faced 26 charges. He was convicted of:

  • nine counts of money laundering,
  • one count of conspiracy to commit money laundering,
  • four counts of payment of kickbacks in connection with a federal healthcare program,
  • two counts of receipt of kickbacks in connection with a federal healthcare program,
  • two counts of conspiracy to commit federal program bribery,
  • one count of conspiracy to defraud the United States and
  • one count of obstruction of justice.

At the Esformes trial, some witnesses testified that conditions in the facilities were poor and care inadequate but that the businessman was able to conceal this information from authorities by bribing Bertha Blanco, a 30-year employee of the Agency for Health Care Administration, which oversees the licensure of assisted living and skilled nursing facilities in Florida, to provide advance notice of surprise inspections.




Dr. Hooshang D. Poor has admitted to Medicare fraud and is facing an indefinite suspension of his medical license faces allegations of sexual assault.  Dr. Poor is facing civil action stemming from an alleged Sept. 16, 2016, assault on a licensed practical nurse who claims Poor groped her from behind while they were working together at the Kindred Nursing and Rehabilitation Tower Hill Nursing Home.

Poor has had other legal troubles in his decades-long medical career.  Last month, Poor agreed to pay $680,000 to resolve allegations of Medicare and Medicaid fraud.

“As a result of Poor’s assault on her, the (nurse) has been seriously and permanently injured, and continues to suffer at present from psychological disease, which impairs and affects all aspects of her life,” the suit states.

The nurse has incurred past expenses for medical treatment and will likely incur more expenses in the future, the suit claims. It also states she has lost income.

Following the assault, the nurse had to avoid coming into contact with Poor when they both still worked at Kindred and since then she has had to avoid him at other nursing homes where she has been employed, which “has caused her to suffer continual emotional upset and interfered with her employment opportunities and schedule,” according to the lawsuit.

The suit states that the nurse promptly reported the assault to the nursing home’s human resources office. It’s unclear if the assault was reported to police.

The Massachusetts Board of Registration in Medicine indefinitely suspended Poor’s medical license on Dec. 20, 2018, after finding that he negligently treated two patients and kept inadequate medical records for four patients.

McKnight’s recently reported that the Government Accountability Office strongly urged the Centers for Medicare & Medicaid Services to respond to recommendations made in the GAO January 2018 report on assisted living.  It has already been more than a year!

The GAO said it will continue to monitor actions taken by the Department of Health and Human Services in response to its recommendation, one of 404 “priority recommendations” — 54 of them at HHS — that were open as of April 7. The agency said it sent letters to the heads of the HHS, Veterans Affairs, and Defense departments “urging them to continue focusing on these issues.”

The 2018 report, “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed” contained a to-do list for CMS including reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities.

Investigators recommended that CMS Administrator Seema Verma:

  1. Provide guidance and clarify requirements for states regarding their monitoring and reporting of deficiencies in assisted living communities.
  2. Establish standard Medicaid reporting requirements that all states could use to annually report information on critical incidents.
  3. Ensure that all states submit annual reports for home- and community-based services waivers on time, as required.

These all seem reasonable and CMS has somewhat addressed #1 and 2.



What a surprise!  The Trump Administration and the Republicans are paying back one of their most significant donors; the nursing home industry lobbyists.  Kaiser Health News released a study showing that nursing facilities have seen their fines drop by more than 30% during the Trump administration.

The industry has been vocal demanding Trump to move away from penalizing providers for each day out of compliance with a regulation. Instead, facilities are issued a single fine for two-thirds of infractions. The average fine dropped from $41,260 to $28,405.

The report notes examples of preferential treatment for nursing homes including an 18-month moratorium on imposing monetary fines for most violations. Trump also revoked a rule that barred nursing homes from requiring residents to sign pre-dispute mandatory arbitration agreements.

Fines need to be large enough to change facility behavior,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, a nonprofit based in Washington. “When that’s not the case and the fine is inconsequential, care generally doesn’t improve.”