Articles Posted in Medicaid and Nursing Homes

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Our state has already had its hand slapped over delayed Medicaid payments and history has just repeated itself. Earlier this month, a judge ruled that Illinois was responsible for delinquent Medicaid application approvals and is allowing seniors who faced delays to sue the state. Seniors who applied for Medicaid after February 1, 2015, who were eligible for the program according to state requirements, and whose care was denied or hindered as a result of a delayed final eligibility determination can pursue action. According to the Centers for Medicare & Medicaid Services (CMS), states have 45 days to process and respond to a Medicaid application. Illinois has 90 days to process Medicaid applications that involve a disability. Many seniors have reported facing delays far greater than 45 days, even after submitting all necessary paperwork.

As a result of delayed approvals, nursing homes have had to discharge current residents and turn away potential residents. Seniors have also reported not being able to receive the care they need, missing out on crucial healthcare, drugs, and services.

Illinois: A Repeat Medicaid Offender

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Reducing Medicaid fraud and waste has been a talking point among many administrations, but with recent reports that 10% of Medicaid payments last year contained an error, several government offices are ready to take action. A meeting between the House Oversight Committee’s Subcommittee on Government Operations and the Subcommittee on Intergovernmental Affairs was planned for this past Wednesday and then cancelled. It was expected that lawmakers from both sides of the table would offer suggestions for reducing waste within the program.  No future meeting date has been announced.

Medicaid Recipients Fearful of Losing Benefits

It’s estimated that fraud and erroneous payments in all public assistance programs cost federal and state governments nearly $140 billion in 2015. Medicaid is considered particularly vulnerable to fraud because there are so many parties involved in the administration of the program. Each state is tasked with day-to-day management of Medicaid, but there are also managed care companies and companies they subcontract with to offer plans. It’s hard for states to police all of the groups involved, making Medicaid a relatively easy area for things to slip between the cracks.

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A major nursing home chain with locations in Aurora, Rockford, and Dixon, Illinois is in the middle of a $60 million lawsuit brought by the U.S. government. The lawsuit alleges that Meridian Senior Living Group (some former Meridian facilities are now owned by Affinity Living Group) submitted at least that amount in false billings to North Carolina’s Medicaid program for services provided in their facilities’ Special Care Units. These units are intended to treat specialized conditions within long term care facilities and nursing homes. The lawsuit names 45 separate Meridian facilities in North Carolina, Meridian’s owner, and their management and billing departments. As a combined entity, Meridian and Affinity operate the most adult care facilities in the state of North Carolina and are one of the top 10 largest adult living networks in the country.

Scam: Too Few Staff for High Billable Care Hours

Information about the scheme was brought forward by a whistleblower who was aware that the submitted claims to Medicaid were purposely overstated to reflect more frequent and extended periods of care than were actually provided. Among other allegations, the whistleblower alleges that the number of staff to the number of residents could never provide for the amount of 1:1 care for which Meridian Senior Living facilities billed. The facilities are accused of charging Medicaid for 1.5 – 1.75 more hours on average than a staff member actually spent with a resident. The lawsuit also alleges that Meridian would bill the maximum allowed per month, regardless of the release date or the date on which a resident was given a diagnosis, a requirement for allowing certain charges to be submitted and reimbursed by Medicaid.

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As congress continues working on the American Health Care Act (AHCA), the bill that will repeal and replace the Affordable Care Act (Obamacare), one of the main issues at hand is a cap on federal contributions to state Medicare & Medicaid budgets. A cut or cap on Medicaid would be tragic for millions of Americans who rely on it to receive long term care.

The National Consumer Voice, an elder advocacy group, cites many reasons why capping medicaid spending would be detrimental. Most notably, the group points out that Medicaid is the only way most elderly Americans can afford a nursing home or long term care. With the average annual cost of nursing home services nearing $84,000, many of America’s elderly can simply not pay for their own care. Medicare covers medically required care in a skilled nursing facility, but the majority of Americans only require custodial care, which includes tasks such as bathing, getting dressed and learning to take medications.

National Consumer Voice also notes that Medicaid helps the elderly stay in their own homes by allowing them access to home health providers that can assist with custodial care.

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Legal challenge for those receiving “at home” care via Medicaid are growing across the country. Medicaid is a joint federal and state program that provides long-term care to the poor and disabled. This is distinguished from Medicare which provides general medical insurance for seniors. When prolonged nursing home visits or caregiving duties at home are needed it is Medicaid, not Medicare, that residents turn to when they cannot afford the services on their own.

Yet, it is no secret that budgets–both state and federal–are quite tight. Medicaid outlays are one of the largest single lines in those budgets, and so long-term financial plans almost always include mention of cuts to these services. Those who rely on Medicaid obviously have legitimate concerns about what this might mean in their specific case. At the end of the day, changes can be mandated both by state officials and the federal government. Each state may take a different track, and so it is important for local residents–when hearing news about proposed Medicaid changes–to understand if the proposal is coming from Illinois, the federal government, or another state altogether.

Legal Challenges

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On October 1, 2011, the Hancock County Nursing Home is shutting its doors, according to the Herald-Whig. Due to Medicaid’s failure to timely reimburse the nursing home for the residents using the program, the facility has no choice but to discontinue operation. Although the facility has received some payments from Medicaid, it is well below the costs of operation. In addition to the lack of financing, the total number of residents in the facility has substantially decreased in recent years. The 57 bed nursing home currently houses only 34 residents.

The nursing facility, which was opened in 1970, explored many options in order to prevent closure. An attempt was made to sell the facility to another operator, but no bids were made. The closing of this facility continues a pattern that has proved to be frequently common in Illinois. In the past several years, over 105 Illinois nursing homes have shut down due to various reasons.

Fortunately, the nursing home is overseeing plans to make sure that all of its residents, as well as, employees are taken care of. The facility has begun individual meetings with residents and their family members to determine which facility they would prefer to transfer to. Additionally, the nursing home plans to help its employees locate comparable jobs after October 1st.

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The Center for Medicaid and Medicare Services (CMS) proposed new regulations yesterday for civil money penalties for nursing homes that violate CMS participation rules. Much of the money used to run nursing homes and provide care to elderly citizens is provided by CMS.

To ensure that the funds are spent in a fair manner and that adequate care is provided, CMS has guidelines that must be followed before a nursing home will be reimbursed by CMS for the cost of provided care to each resident. Also, CMS has the power to impose penalties on nursing homes that violate the CMS requirements.

The new regulations proposed yesterday were mandated by the landmark healthcare reform law passed last year. Our Chicago nursing home lawyers at Levin & Perconti support any new law that holds failing nursing homes accountable for elder abuse and negligent care that is too often provided to senior residents. Our clients have continually shared stories of substandard care at these facilities, often leading to deadly results. Threatening the money streams to the nursing home facilities is sometimes the only way to ensure that nursing home administrators finally ensure that their employees are properly trained, the facility is secure, and all nursing home laws are followed.

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Yesterday, President Obama appointed Dr. Donald Berwick as the new Administrator of the Centers for Medicare and Medicaid Services (CMS). CMS is the federal agency that regulates nursing homes and all other facilities that receive Medicare and Medicaid funds.

The National Consumer Voice for Quality Long-Term Care, one of the nation’s foremost nursing home reform organizations, issued a statement on President Obama’s choice, explaining how they believe Dr. Berwick will handle nursing home law issues.

Many have criticized the President for making a “recess appointment,” essentially meaning that Dr. Berwick will not require Senate approval be officially be given the job. However, the Consumer Voice notes that the CMS position had not been permanently filled since 2006, and that immediate action was needed to ensure that America’s health and long-term care systems were being properly administered.

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A recently filed Justice Department lawsuit alleges that Johnson & Johnson paid tens of million of dollars in kickbacks to boost sales of its drugs in nursing homes. One of these drugs included an antipsychotic that can be used as a chemical restraint. The payments were disguised as grants or educational funding. They were funneled through Omnicare, which is a pharmacy company that dispenses drugs in nursing homes. They used their influence with doctors to have prescriptions switched to name Johnson & Johnson. This puts profits ahead of medical care and can distort the judgment of health care professionals. This is just another case in a series of nursing home lawsuits that allege companies have used illegal inducements to skew medical decisions and promote their products. The biggest problem is that Johnson & Johnson allegedly caused false or fraudulent claims to be filed with Medicaid. The patients at issue include those suffering from Alzheimer’s and other forms of dementia. This recent case greatly effects how pharmaceuticals are dispensed in nursing homes. To learn more about the nursing home kickbacks, please check out the link.

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A physician has been reprimanded by the state medical registration board for elderly negligence. The doctor mishandled the care of an 88-year-old man when he changed his medications. He also failed to inform the victim’s cardiologist and gave the patient “unrealistic instructions” for handling his own medicines. In 2008 the doctor agreed to pay $150,000 to settle allegations that he submitted fraudulent claims to the Medicare and Medicaid programs for office and nursing home errors. He has become entangled in the federal probe because of the nursing home errors by the billing service. To read more about the doctor’s fraudulent claims, please click the link.