Articles Posted in Medicaid and Medicare Fraud

nursing home operator on way to prison

Virginia Nursing Home Operator Found Guilty of Health Care Fraud

In Norfolk, Virginia, the operator of Turning Points Residential Care has been sentenced to two years in prison for defrauding Medicaid. According to July 2, 2021 court documents, 47-year-old Lopez Scott submitted more than $188,000 in false claims for a residential nursing facility his business was authorized to use to provide residential support services and skilled nursing services to recipients of Medicaid.

“For three years, the defendant used his position as a nursing home operator to obtain over $188,000 from the Virginia Medicaid program fraudulently,” said Raj Parekh, Acting U.S. Attorney for the Eastern District of Virginia. “Health care fraud takes funding and critical services away from those who truly need it. We will continue to hold accountable those who exploit these essential health care programs at the expense of vulnerable members of our communities.”

healthcare fraud

Miami-Dade Nursing Home Owner Convicted in Largest U.S. Healthcare Fraud Scheme

Just last week, a 12-person jury deliberated for four days before finding Philip Esformes, a 50-year-old entrepreneur and owner of a network of 16 nursing homes and assisted living facilities in Florida, guilty on 20 out of 26 charges related to healthcare fraud. This is believed to be the largest fraud scheme ever charged by the U.S. Justice Department and a reflection of the business owner’s greed through receiving kickbacks, money laundering and conspiracy to commit federal program bribery totaling $37 million. In an April 5th, 2019 public statement, prosecutors called him a “despicable,” “vampire” who was fueled by “unbounded greed.”

“Esformes exploited and victimized patients by providing inadequate medical care and poor conditions in his nursing homes. We will continue the fight against such parasites.”

“Frail and vulnerable people are harmed when nursing homes fail to meet our standards. And I don’t think any of us wants to wait until the next natural disaster or other disaster exposes some kind of a deficiency that kills dozens of people.”

                                                 -Rep. Diana DeGette (D-CO)

On Thursday, the House Subcommittee on Oversight and Investigations held a hearing to address substandard care and recent findings of abuse and neglect in U.S. nursing homes.

A new trend has emerged in several states including Pennsylvania & New Mexico: Attorneys General partnering with private law firms to sue large nursing home chains for negligent care, Medicare/Medicaid fraud, and deceptive marketing tactics. An article in a December edition of Reading Eagle, a Reading, PA newspaper, puts a spotlight on this growing movement to improve the quality of care received at nursing homes in all states. In Pennsylvania alone, Attorney General Bruce Beemer has filed 3 lawsuits (one of which has since settled) against 3 of Pennsylvania’s largest nursing home chains in the past year and a half. The case versus Reliant Senior Care (now Priority Healthcare Group) settled for a reported $2 million and was the largest nursing home settlement in PA won by an attorney general. The other two chains who are still locked in a legal battle against the state are Golden Living Centers and Grane Health Care.

Sending a Message

Nursing home industry advocates are obviously unnerved by partnerships between attorneys general and private law practices who have a history of success in helping right the injustices caused by big business on the American people. While these advocates argue that private law firms are giving donations to campaigns for attorneys general to essentially guarantee they’ll be called upon for future work, the law does not seem to be on their side. The State of Pennsylvania was unsuccessfully sued by the nursing home industry for such practices.  Elderly advocates believe working relationships between public and private legal entities will send a message to the industry that American taxpayers expect more from facilities receiving Medicare & Medicaid tax dollars.

A lawsuit was filed on December 21 in Maryland against Neiswanger Management Services, LLC (NMS) for improperly evicting elderly residents from their facilities without plans for their medical care. Maryland law requires nursing homes to have care plan for residents upon being discharged. NMS is accused of kicking out residents as soon as their Medicare benefits have been depleted, leaving resident’s belongings outside and sending some to homeless shelters or unlicensed facilities.

Maryland’s Attorney General, Brian Frosh, said that a review of NMS revealed that despite only operating 2 percent of the nursing home beds in Maryland, “they represent 66 to 70 percent of the evictions.” Frosh believes that NMS has been replacing evicted Medicare residents with those on Medicaid, as Maryland’s daily rate is higher for Medicaid patients than it is for those on Medicare.

Recent news provides another example of the effort of medical providers, such as nursing homes, to defraud the government through healthcare fraud. The agencies are Adonis Inc. and BestMed-Care Services Ltd., headquartered in Dolton, Illinois. The operator of two nursing home agencies in Illinois was arrested and charged with healthcare fraud. The allegations specified that he stole over $5 million “for unnecessary home care services” for nearly four years. The charge carries a maximum penalty of 10 years behind bars and a fine of the greater of $250,000 or twice the amount of the fraud.

The charges stem from the agencies paying a marketing company to refer patients to them for ostensibly “free services” only to tell the patients they needed certain care from skilled nurses, and then billing Medicare for providing that unnecessary care. This also included filing falsified nursing assessments for these patients. This most recent case again puts the spotlight on the importance of Medicare and Medicaid Fraud Units. In this case, the Medicare Fraud Strike Force’s investigation led to this arrest. It also highlights the importance of our laws in combating Medicare and Medicaid fraud to protect the system and patients:

False Claims Act
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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.
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Earlier this week we shared information about programs which train seniors to identify questionable items on medical bills in the hopes of rooting out errors and fraud. As mentioned, even individual mistakes on simple items–like accidentally billing for double medication–can add up over the long-term. It is important to constantly improve billing efficiency to ensure all public money is well spent.

But even more invidious are those cases where there are systematic problems in billing. Nursing homes are frequently the site of these Medicare and Medicaid fraud schemes. When left unchecked, hundreds of millions of dollars or more can be filtered to service providers for services that were not performed adequately or at all. It is vital that those with information about these schemes–including seniors, nursing home care workers, and others–to come forward, speak with an attorney, and ensure the fraud is stopped.

Nursing Home Bill Inflation Case

Senior citizens are uniquely familiar with the large healthcare programs Medicare and Medicaid. Medicare in particular is available only for seniors. Alternatively, Medicaid is based on financial need–one must have assets below a set figure to qualify. Medicaid is critical for many seniors, as it pays for permanent long-term care at nursing homes, whereas Medicare does not pay for extended stays. Any way you look at it, however, these programs are critical to the health and well-being of seniors in Illinois and throughout the country.

That is why the elderly–and their family members–have a huge stake in the financial stability of the programs. Lawmakers are constantly discussing possible changes, mostly spurred by concerns about budgets. One easy way to help the budget problems is to root out fraud and ensure that all funds spent on the programs are effective and useful. Unfortunately, billions of dollars allegedly are lost each and every year as a result of mistakes and outright fraud. The losses accrue when the programs are billed for services that are not provided, unnecessary, or provided inadequately.

Training Seniors to Spot Problems

There is often a close relationship between hospitals and certain nursing homes. Seniors who live in nursing homes usually have various medical issues which may require hospital care on a frequent basis. In fact, some of the most common forms of nursing home neglect is when caregivers fail to call an ambulance to rush a resident to a hospital to receive emergency care. It is critical to remember that nursing homes, while providing some skilled care, are not hospitals. These facilities are limited in what care they can provide, and it is incumbent upon caregivers at these homes to know when it is necessary to transport a resident to a hospital.

But therein opens another problem. Because nursing homes are such a large referrer of patients to hospitals–and both may be for-profit facilities–there is a risk of fraudulent relationships developing. That may include situations where residents are referred to certain facilities at certain times in order to boost the bottom line of both operations. In the worst cases, administrators may actually provide kickbacks to nursing homes for referring residents to one hospital over another.

Illinois Example

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