The NonProfit Quarterly had a great article on for-profit nursing homes defrauding Medicare by providing therapy to sick and dying residents to pad their profit margins.  Such are the main findings of a study authored by four professors from the University of Rochester School of Medicine, published in the Journal of the American Medical Directors Association.

“Nursing home residents on the verge of death are increasingly receiving intense levels of rehabilitation therapy in their final weeks and days, raising questions about whether such services are helpful or simply a lucrative source of revenue,” reports Tara Siegel Bernard in the New York Times. The practice, she notes, was twice as prevalent at for-profit nursing homes as nonprofit ones.

The fact that the study found this practice to be twice as common at for-profit nursing homes than non-profit nursing homes is not surprising. As NPQ’s Karen Kahn wrote earlier this year, “Multiple studies over the last two decades indicate that for-profit ownership of nursing homes, particularly for-profit chain ownership, correlates with substandard care.” Unfortunately,  for-profits control nearly 70 percent of all nursing homes.

Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy, notes there are two problems: “Nursing facilities are providing more therapy than needed in order to increase their reimbursement, and nursing facilities are not providing appropriate maintenance therapy to residents who need it.

 

A new study contends that nursing homes may be pushing dying patients into unnecessary and potentially harmful high-intensity rehab services. University of Rochester Medical Center researchers noted that the number of residents receiving “ultra-high” rehab services in New York state increased by 65% during the three-year period ending in 2015. Most of those services were delivered to individuals in the last seven days of their lives, according to the analysis of data from 647 nursing homes in the Empire State that was published week in the Journal of the American Medical Directors Association.

“These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits,” Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study, said in a statement. “It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering.”

Researchers honed in on residents in the Very High (520 minutes per week) to Ultra-High (720 minutes) groupings of rehab services in the last 30 days of life.

 

The new study raises questions about the use of high-intensity therapy minutes at the end of residents’ lives.  Between 2012 and 2016, ultra-high rehabilitation services provided to nursing home residents in their final month of life spiked 65%, according to research from the University of Rochester, with overall end-of-life therapy use rising 20%. In addition, residents of for-profit nursing homes were almost twice as likely to receive high- to ultra-high therapy than those in non-profit buildings.

Those findings mirror trends identified by the Department of Health and Human Services Office of the Inspector General (OIG), lead researcher Helena Temkin-Greener told Skilled Nursing News.

The OIG found that between 2011 and 2013, the overall proportion of ultra-high therapy minutes grew from 49% to 57%, raising general concerns about the necessity of such services. Writing in the study, published in the October issue of JAMDA — The Journal of Post-Acute and Long-Term Care Medicine, Temkin-Greener and her colleagues noted that the OIG identified a hospice resident who asked to stop receiving therapy — but continued to receive physical therapy services five days per week for more than a month.

 “They don’t seem to be associated with changes in resident characteristics,” Temkin-Greener, a professor emeritus at the University of Rochester’s Department of Public Health Services, said. “So the residents’ care needs appear to stay the same over a period of time, but [there are] increases in the use of ultra-high therapy.”

Temkin-Greener specifically cited the gap between for-profit and non-profit nursing home therapy as a reason for concern.

“That gives me pause. If receiving high- to ultra-high therapy is a good thing at the end of life, then I shouldn’t be seeing such a significant finding, with two-fold higher odds of receiving it in nursing homes associated by profit status,” she said. “If it’s good for everybody, everybody should get it. If it’s bad for everybody, nobody should get it. I’m sure there are shades in between, but I shouldn’t be seeing profit status as an indicator.”

Based on those results, the team concluded that financial pressures may frequently play a role in the therapy decision-making process at nursing homes.  CMS specifically cited the potential for abuse under the old system as a key driver of the payment overhaul.

“When a nursing home has more RNs per resident per day, the use of ultra-high therapy decreases at the end of life,” she said. “So that suggests that higher skill allows people to recognize that a patient is dying, actively dying, and not provide ultra-high therapy.”

Gena Randolph, a South Carolina speech therapist, was convicted in federal court for a scheme where she stole $2 million from federal health care programs, according to a media release from U.S. Attorney Sherri A. Lydon.  Randolph could be sentenced to more than 30 years behind bars after being convicted of health care fraud that included bogus claims of speech therapy for dead people, according to the U.S. attorney’s office.

However, this is not the first time Randolph has been in trouble with the law which begs the question:  Why was she able to participate in the Medicare program at all?

Randolph was convicted in 2012 for filing false claims with the South Carolina Medicaid Program.  That conviction meant Randolph “was prohibited from working for any provider to perform services paid for, in whole or in part, by Medicare and Medicaid,” according to the U.S. attorney.  In spite of that, Randolph continued to submit claims to Medicare and Medicaid, “only she was disguising her ownership and control over Palmetto Speech and Language Associates and Per Diem Healthcare Services.”

Evidence presented in her trial showed how Randolph executed her scheme.  Randolph “submitted claims both for speech therapy services that either were provided by other speech therapists, and for services that were never rendered at all.”   Randolph even “submitted claims for services to beneficiaries who were dead,” Lydon’s office reported.

 

 

The Greenville News recently published a story about a different kind of hero–Dr. Michael Mayes.  Since 2010, he’s worked mostly in secret to gather information, turn it over to the government and help build a federal case to expose national Medicare fraud that affected his own patients on Hilton Head — and those around South Carolina and the nation too.  If Mayes hadn’t risked his career, relationships with fellow physicians and future job prospects, the fraud could still be going on today.

His work exposed a national scam where physicians ordered panels of lab tests that were not medically necessary for their patients and received illegal kickbacks. As a result, Medicare, and other government healthcare programs, paid upward of $500 million in fraudulent claims.  Mayes’ whistleblower lawsuit, the first of three, was filed under seal in 2011 and later taken over by the federal government. His name was not revealed until 2015 when the first settlement in the case was announced.

He was the only physician to come forward.  The taxpayers of South Carolina owe him a debt for his courage and integrity.

The federal anti-kickback statute, which prohibits laboratories from “offering or paying any renumeration, in cash or kind, directly or indirectly, to induce or influence physicians” to order tests that “may be paid for by federal health care programs,” according to the federal complaint.

In June 2011, a lawsuit was filed alleging Berkeley, BlueWave Healthcare Consultants and LipoScience “routinely” paid kickbacks to physicians to convince them to order tests. LipoScience was later dropped from the suit, because what it had done was “significantly less egregious” than the others.  Later, Health Diagnostic Laboratory, Singulex and Quest Diagnostics — a company that purchased Berkeley in 2011 — were added to the suit.

In January 2012, Quest Diagnostics decided to stop offering the payments to physicians.  When the payments stopped, Mayes noticed physicians stopped ordering the tests.

“Once they stopped paying for the tests, the number of tests ordered was drastically reduced,” Gaudette said. “In my opinion, money had a lot to do with it.”

According to the federal complaint, Quest then tried to get doctors to continue ordering the tests by offering to pay phlebotomists’ salaries and leasing office space from the practices, among other things.  One cardiologist said his practice was bringing in $17,000 a month by ordering the tests, or about $200,000 a year.

In June 2014, the Office of Inspector General issued a special fraud alert about these payments to physicians.

In 2015, Health Diagnostic Laboratory and Singulex agreed to pay $48.5 million to settle claims that they violated the False Claims Act.

And in 2016, Quest Diagnostics agreed to pay $6 million to settle the same allegations.

Mayes testified as a witness for the government — the only whistleblower to do so — in January 2018 in Charleston. Three individuals associated with Health Diagnostic Laboratory and BlueWave chose not to settle and were tried by jury. The jury sided with the government after the two-week trial. In May, a $114 million judgment against the three was announced.

Health Diagnostic Laboratory filed for bankruptcy, and trustees have since filed suit against individual physicians who received a “significant” amount of money from the kickbacks, Mayes said.

Mayes, and the other whistleblowers, helped put an end to the scheme.  Part of choosing to talk about the case, Mayes said, is because he believes patients should be aware of fraud, and those who commit it should be held responsible.

According to Medicare.gov, here are a few precautions patients can take to protect themselves from fraud:

▪ Save dates, receipts and statements for healthcare services you receive.

▪ Compare your records with statements from Medicare to make sure the services and dates match up. If those records don’t match, it’s possible Medicare was billed for services you didn’t receive.

▪ If a charge seems incorrect, call the provider’s office to inquire about it.

▪ If you suspect there is Medicare fraud, report it online or by calling 1-800-633-4227.

McKnights reported on Senator Ron Wyden’s letter to Centers for Medicare & Medicaid Services Administrator Seema Verma demanding answers on how the federal government plans to better hold nursing homes accountable for their conscious decision to short-staffing nursing homes.  His concerns stemmed from the “upsetting” front-page New York Times article, published in July, which concluded that “payroll records provide the strongest evidence that, over the last decade, the government’s five-star rating system for nursing homes often exaggerated staffing levels.”  Wyden noted in his letter that the healthcare system has evolved greatly in the decade since the rating system was established. He believes the federal government must do the same with how it measures nursing home quality.

Many staffing experts, nursing home advocates, and consumer groups are also concerned that the short-staffing causes poor quality of care and leads to neglect and abuse.

The senator also expressed concerns about info unearthed from Payroll-Based Journaling collections. Mainly that, 7 in 10 homes were found to have lower staffing using the new methods, with a 12% average decrease. “If true, it is concerning that seniors and their families have been receiving inaccurate or erroneous information about the staffing levels provided by a SNF.”

Wyden gave Verma an Aug. 24 due date to provide answers to the following valid questions:

1) What are the safeguards CMS has in place to ensure SNFs provide accurate information?

2) What is the difference in staffing levels between self-reported and payroll data methodologies?

3) What will the agency do if it finds self-reported data to be inaccurate?

4) Would CMS update staffing quality measures to account for inappropriate fluctuations in staffing? and

5) Would CMS consider measuring patient and family staff satisfaction as part of Five Star?

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.