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.”



Tennessee Health Management nursing company has agreed to pay $9.8 million to settle allegations that it forged physician’s signatures to certify patients’ entry into its facilities. For violating the False Claims Act, THM has agreed to pay almost $5.5 million to the U.S. government and $4.3 million to the state of Tennessee, the Department of Justice reported.   Instead of prohibiting them from receiving any more tax payer money, CMS is allowing the company to enter a federal corporate integrity agreement to improve practices and avoid further such conduct.  That is ridiculous considering how long THM participated in this illegal conduct.

For at least an eight-year period, Tennessee Health Management submitted pre-admission evaluations to both the state and federal authorities, with photocopied or pre-written signatures from physicians. Doctors must conduct a patient-placement evaluation prior to an individual entering a nursing home.


The Department of Justice accused Conway Lakes Health & Rehabilitation Center of arranging to pay an orthopedic surgeon to illegally refer Medicare patients for post-surgery services at the SNF.  That is an illegal kickback.  That orthopedic surgeon, Dr. Kenneth Krumins, allegedly took part in a similar scheme with a related home health agency, the DOJ said.  Nursing home management then disguised those payments to Krumins by giving him a “sham” title as medical director of the facility.

“Disguising intricate kickback arrangements through directorships and other misrepresented positions corrupts physician decision making and undermines the public’s trust in the healthcare system,” Shimon Richmond, a special agent with the U.S. Department of Health and Human Services’ Office of Inspector General, said in a statement.

The arrangements clearly violated physician-referral rules, commonly called the Stark Law, and anti-kickback statutes. Krumins has agreed to pay $500,000 to settle the allegations, while Conway Lakes, its administrator, management company and others must pay another $1 million. Claims were brought forward by a former employee and whistleblower, who will share in $267,000 of the proceeds.


McKnights reported on the ongoing saga between National Health Corp. and one of its former nurse leaders, Mary Lea Byrd. In 2012, she filed a complaint, alleging that NHC violated the False Claims Act in numerous ways.  Byrd has now filed an amended complaint, alleging that the skilled nursing provider illegally retaliated against her whistleblowing actions, eventually forcing her to resign. National Health Corp. — whose affiliates operate 76 skilled nursing centers — had moved to dismiss the complaint, because they believe it was barred by the three-year statute of limitations for violations of the False Claims Act.

In her original complaint, Byrd — who was hired as a director of nursing at a Farragut, TN, SNF in 1998 — alleged that NHC required patients to bring medication from home, upcoded claims, billed for services not rendered, and kept patients on services when they no longer qualified for skilled care. She alleges that, after she surfaced those allegations, NHC retaliated in various ways on at least five separate occasions, increasing pressure on her to quit. In September 2017, she felt she had “no choice but to resign,” giving her 30-day notice.

After the case was unsealed in 2017, Byrd filed an amended complaint, naming “National Health Corp.” rather than the original NHC. Those two are affiliated related entities, with common ownership and common control to the national for-profit chain. National Health Corp. argued that its access to a copy of the original complaint was not enough to make it aware that this particular retaliation claim had been filed, a contention with which a U.S. District Court of Eastern District of Tennessee judge disagreed last week.

To say that an organization so closely intertwined with another would not be aware of ongoing litigation arising from a FCA claim is, at best, a stretch,” wrote Judge Pamela L. Reeves.



McKnight’s did a deeper dive into the recent Kaiser Health News analysis which revealed that only about 27% of the nation’s nursing homes are receiving a bonus payment for reducing hospital readmissions within 30 days.  “The report noted that for-profit nursing homes — which account for about two-thirds of America’s skilled nursing facilities — are facing deeper payment cuts on average compared to their nonprofit and government-owned counterparts.” Providers in the southern States have been hit hardest. The vast majority failed to reduce preventable hospitalization therefore will suffer a penalty.  Hopefully, this will deter future failures and incentive better care.  Meanwhile, more than half of SNFs in Alaska, Hawaii and Washington are receiving bonuses.

The KHN website features an online tool to look up which nursing homes received a bonus payment or penalty under the program.

Altogether, 10,976 nursing homes are being penalized under the SNF Value-Based Purchasing Program while 3,983 are getting bonuses. The rest will not experience any change in payment, KHN noted.

Incentives were based on both how SNFs’ hospitalization rates in calendar 2017 compared with other facilities, and how much rates changed since 2015. With the incentives, Medicare is redistributing $316 million from poor-performing SNFs to the facilities that excelled.

The new bonus-penalty scheme is not a zero-sum game. Medicare will keep $211 million that it would have otherwise paid to nursing homes if the program did not exist.

NPR reported on the federal government’s new step to reduce avoidable hospital readmissions of nursing home patients. They are using the carrot and the stick approach.  Reward those who complied and improved, and punish those who have not.  Money is the chief motivator of many for-profit nursing homes so CMS is targeting their profit margins.

The new Medicare program is altering a year’s worth of payments to 14,959 skilled nursing facilities, based on how often their residents ended up back in hospitals within 30 days of leaving. The move will lower a year’s worth of payments to nearly 11,000 nursing homes, and giving bonuses to nearly 4,000 others.  Over this fiscal year, which began Oct. 1 and goes through the end of September 2019, the best-performing homes will receive 1.6 percent more for each Medicare patient than they would have otherwise. The worst-performing homes will lose nearly 2 percent of each payment. The others will fall in between.

These financial incentives, determined by each home’s readmission rates, significantly expand Medicare’s effort to pay medical providers based on the quality of care instead of just the number or condition of their patients.

Nearly 11 percent of patients in 2016 were sent to hospitals for conditions that could have been averted with better nursing and custodial care.

These bonuses and penalties are also intended to discourage nursing homes from discharging patients too quickly — something that is financially tempting as Medicare fully covers only the first 20 days of a stay and generally stops paying anything after 100 days.

For-profit nursing homes, which make up two-thirds of the nation’s facilities, face deeper cuts on average than do nonprofit and government-owned homes, a Kaiser Health News analysis of the data found.

Congress created the Skilled Nursing Facility Value-Based Purchasing Program incentives in the 2014 Protecting Access to Medicare Act. In assigning bonuses and penalties, Medicare judged each facility’s performances in two ways: how its hospitalization rates in calendar year 2017 compared with other facilities and how much those rates changed from calendar year 2015.

Facilities received scores of 0 to 100 for their performances and 0 to 90 for their improvements; the higher of the two scores was used to determine their overall score. Facilities were then ranked highest to lowest.


Healthcare Analytic News reported on a new study published by the Health Information Science and Systems journal that may lead to billion dollar savings in Medicare reimbursement.  Machine learning may become a useful tool in discovering Medicare fraud reclaiming anywhere from $19 billion to $65 billion lost to fraud each year.

Researchers from Florida Atlantic University’s College of Engineering and Computer Science used Medicare Part B data, machine learning and advanced analytics to automate fraud detection. They tested six different machine learners on balanced and imbalanced data sets, ultimately finding the RF100 random forest algorithm to be most effective at identifying possible instances of fraud. They also found that imbalanced data sets are more preferable than balanced data sets when scanning for fraud.

“There are so many intricacies involved in determining what is fraud and what is not fraud, such as clerical error,” Richard A. Bauder, senior author and a Ph.D. student at the school, said. “Our goal is to enable machine learners to cull through all of this data and flag anything suspicious. Then we can alert investigators and auditors, who will only have to focus on 50 cases instead of 500 cases or more.”

In the study, Bauder and colleagues examined Medicare Part B data from 2012 to 2015, which held 37 million cases, for instances such as patient abuse, neglect and billing for medical services that never occurred. The team narrowed the data set to 3.7 million cases, a number that would still represent a challenge for human investigators who are typically charged with pinpointing Medicare fraud.

The authors used the National Provider Identifier — a unique ID number issued by the government to healthcare providers — to match fraud labels to Medicare Part B data, which comprised provider details, payment and charge information, procedure codes, total procedures performed and medical specialty.

When researchers matched the NPI to the Medicare data, they flagged potentially fraudulent providers in a separate database. “If we can predict a physician’s specialty accurately based on our statistical analyses, then we could potentially find unusual physician behaviors and flag these as possible fraud for further investigation,” Taghi M. Khoshgoftaar, Ph.D., co-author and a professor at the school, said.

Surprisingly, researchers found that keeping the data set 90 percent normal and 10 percent fraudulent was the “sweet spot” for machine-learning algorithms tasked with identifying Medicare fraud. They thought the ratio would need to include more fraudulent providers for the learners to be effective.

According to Herald-Mail Media, Matthew Neiswanger, a former nursing home owner, settled allegations of Medicare Fraud with the Maryland’s State Attorney General’s office for $2.2 million. The former owner paid the 2.2 million to the State Attorney’s Medicaid Fraud Control Unit.

The state attorney office found Neiswanger was submitting false claims to Maryland’s Medicaid office. The facility would issue eviction notices to its patients, and the patients would have to resort to homeless shelters or non-licensed facilities. It is important to note that there were four other nursing home facilities named within the lawsuit. NMS frivolously countersued the Maryland Department of Health and four of its employees, but the countersuit was later dropped.

Another condition of the settlement was that Neiswanger is no longer to operate in the state of Maryland. However, this doesn’t prevent him from moving to another state to continue his fraudulent acts.


The CMS on published additional quality measures on Nursing Home Compare for skilled-nursing facilities. The release of the new quality data was mandated by Congress as part of the Improving Medicare Post-Acute Care Transformation Act of 2014. The IMPACT Act established the Skilled Nursing Facility Quality Reporting Program, which requires SNFs to report quality performance on several measures or risk a 2 percentage point Medicare payment reduction.

There are currently five measures included in the program: Percentage of SNF patients who develop new or worsened pressure ulcers; percentage of patients whose activities of daily living and thinking skills were assessed and related goals were included in their treatment plan; percentage of patients who experience one or more falls with major injury during their SNF stay; Medicare spending per beneficiary for patients in SNFs; and rate of successful return to home or community from a SNF.

The CMS opted not to add the potentially preventable 30-day post-discharge readmissions measure. The agency said it needs additional time “to determine if there are modifications that may be needed both to the measure and to the method for displaying the measure.”

The average rate of patients who developed new or worsening pressure ulcers during their stay in a SNF was 1.7%, according to the CMS. The average rate of patients whose activities of daily living and thinking skills were assessed and related goals were included in their treatment plan was 95.8%.  And the average rate of patients who returned home from the SNF and remained alive without hospitalization for 31 days after discharge was 48.6%.

There are other quality measures available on Nursing Home Compare like percentage of short-stay residents who report moderate to severe pain or percentage of long-stay residents who got an anti-anxiety or hypnotic medication.  More than 15,000 nursing homes in the U.S. have quality data on Nursing Home Compare.

    • CMS releases Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data

Nursing Home Compare now includes SNF QRP quality data that allows you to compare SNF providers by their performance on important indicators of quality. The following 5 SNF QRP measures are now being displayed on Nursing Home Compare:

Assessment-based measures:

        • Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short-stay)
        • Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function
        • Application of Percent of Residents Experiencing One or More Falls with Major Injury

Claims-based measures:

        • Medicare Spending Per Beneficiary
        • Discharge to Community
  • New quality of resident care measure for unplanned hospitalizations among long-stay residents
  • Beginning with the April 2019 Nursing Home Compare refresh, the downloadable database will be provided in .csv format only. We will no longer post the Access format.
  • Because we’re implementing a new Nursing Home health inspection process, CMS changed how the star ratings are calculated.