Poor Nursing Home Care May Have Cost Medicare up to $2.8 million in 2011

It is no secret that government insurance programs like Medicare and Medicaid, which are meant for the elderly and the poor, respectively, serve as chief revenue sources for nursing homes and long-term care facilities. Thus it is vital for facilities to meet certain regulations and levels of care under federal and state laws so that they can remain eligible to earn Medicare and Medicaid reimbursements for those insured residents. Unfortunately, this strong revenue stream can be abused, as when medical providers such as nursing homes overbill, bill for unnecessary treatments, or bill for treatments that never actually occurred, all to charge the government, and thus us taxpayers, more.

As examined in a New York Times article in mid-April, the Office of Inspector General of the United States Department of Health and Human Services, which has the overall authority over federal health matters including Medicare and Medicaid, released a report last year that showed a tremendous amount of spending on nursing homes through Medicare while far too many residents were actually injured from the medical care. This is allegedly stemming from a hard push by nursing homes to bring in more Medicare dollars by attracting patients that otherwise don’t need nursing homes, such as those needing short-term care of rehabilitation, rather than the typical long-term care.

Yet these facilities may not be adequately equipped to provide the proper treatments and rehabilitation for these types of patient residents. A quick snapshot of the problem as explained in the report’s Executive Summary, approximately “22 percent of Medicare beneficiaries experienced adverse events during their SNF [skilled nursing facilities] stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays.” The short stays examined were of 35 or fewer days. Disturbingly, 59% of the harmful events likely could have been prevented. A whopping 79% of these events resulted in either “prolonged SNF stay[s], transfer to a different SNF or other post-acute facility, and/or hospitalization.” About 14% needed “intervention to sustain the resident’s life,” while 6% unfortunately led to resident deaths.

The Financial Cost of Nursing Home Abuse

The blame rests on “substandard treatment, inadequate resident monitoring, and failure or delay of necessary care.” As a result of further illness or injury from this substandard treatment, residents often must go back to a doctor or hospital, or stay longer in a nursing facility, which in fiscal year 2011 is estimated to have cost Medicare $2.8 billion to treat injuries caused at nursing homes. That is potentially up to $2.8 billion that did not have to be spent if residents were put in the right facilities and treatment plans for their rehabilitations. And as a reminder, those Medicare dollars are taxpayer dollars.

As the Times reports, Medicare pays 84% more for short-term residents than what Medicaid normally pays for longer term poor residents. On top of this, some hospitals release patients early to shave costs, and this may result in a patient going to a nursing home facility, even for a short term rehabilitative stay. Thus nursing homes are trying to take advantage of this growing market of patients. This makes it more important than ever for state health agencies and the U.S. Department of Health and Human Services to stay on top of these nursing homes to ensure that proper care is given. It may also necessitate a broader reform in the future to ensure patients are not sent where they will not receive the right care.

See Related Blog Posts:

Medicare Fraud in Illinois Highlights Importance of Law Enforcement

Medicaid Fraud Units Also Target Abuse and Neglect

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