The False Claims Act is a law that allows for the government to sue those who have allegedly defrauded the federal government. These lawsuits can also be filed by individual citizens who believe they have uncovered evidence of fraud against the federal government, and the United States Department of Justice has the option to get involved and prosecute the matter.
Medicare & Medicaid Fraud in Nursing Homes
In the healthcare industry, there are often many examples of fraud in the context of Medicare and Medicaid. Medicare and Medicaid are of course programs administered by both federal and state governments, largely with federal dollars. In exchange for accepting money for either program, states and healthcare providers must follow certain rules and regulations as to how they conduct themselves and do business. If all goes well, those providers can then submit for reimbursement from Medicare and Medicaid. However, many providers unfortunately will overbill these programs in order to get back more money, which is pure and simple a fraud perpetrated on the government. Many states have their own versions of the False Claims Act, and can also be the target of fraudulent activity.
In Baltimore, Maryland earlier this summer, a healthcare provider called foundation Health Services Inc., as well as its nursing facilities and its president and CEO all agreed to settle a false claims case against them, agreeing to pay $750,000. This settles claims against them by both the U.S. government as well as the Maryland state government, which handled the case through the U.S. Attorney’s office in Maryland, the Department of Health and Human Services Office of Inspector General, and the Maryland Attorney General’s Office. The company is based in Louisiana but owns and operates nursing facilities in various stats, including Maryland and within the city of Baltimore.
The investigation of these facilities began after one of the facilities evacuated residents because of an air conditioning problem in the midst of a scorching holiday weekend when temperatures reached 100 degrees. This investigation in the middle of a heat wave led to discoveries of inadequate services for which the facilities were seeking reimbursement from Medicare and Medicaid.
Submitting False Claims
According to a DOJ press release, the nursing homes “submitted false claims for payment to Medicaid and Medicare for materially substandard and/or worthless skilled nursing facility services.” In doing so, as alleged, the facilities did not follow protocols as they related to resident falls, did not address ulcer infections properly, did not give patients their medications properly, failed to monitor, clean and feed the patients, and failed to appropriately handle a variety of other situations. In failing to properly care for the patients and to not provide an appropriate number of skilled staff members at the facility, it was inappropriate for the facilities to seek reimbursement from Medicare and Medicaid for those insured by these programs, because in reality they did not truly provide the adequate services as required to gain eligibility for reimbursement.
Healthcare providers must know that it is unlawful to submit false claims for reimbursements under Medicare of Medicaid, let alone any other program. Such fraud can result in both criminal and civil charges. Individuals must also be careful in this regard.
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