False Claims Investigation

All posts tagged False Claims Investigation

SNF Reimbursement Model Leads to False Claims

by admin on July 6, 2021 No comments

Medical necessity is foundational to payment by government payers (Medicare, Medicaid, Tricare, FEHBP) for health care services.  If services are not medically necessary, any claims filed constitute false claims. In a recent DOJ False Claims Act (FCA) case, a civil settlement of a whistleblower action was reached in resolution of allegations that over a more than six-year period, a rehabilitation therapy contractor violated the FCA by causing the submission by 12 skilled nursing facilities (SNFs) of false claims for “medically unnecessary, unreasonable, and/or unskilled rehabilitation therapy services.”  Under the Settlement Agreement, the rehabilitation therapy provider agreed to pay $8.4 million to resolve the matter.

BACKGROUND ON SNF REIMBURSEMENT

In order to understand the case, it is important to understand (at least at a basic level) SNF reimbursement.  This case arises during the time period 2010-2016 when SNFs were paid by Medicare under the Resource Utilization Groups (RUGs).  By way of background, RUGs are a prospective payment model which includes a system of grouping a SNF’s residents according to their clinical and functional statuses which information derives from the minimum data set (MDS) assessment for the resident.  Soon after adoption, many SNFs and rehabilitation therapy providers adjusted their model of care delivery to increase the level of reimbursement.  The methodology created an incentive to deliver more therapy than skilled nursing services since those RUGs were reimbursed at a higher rate.

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Civil Investigative Demand: What to Expect in a Heightened Regulatory Environment

by admin on November 6, 2017 No comments

DOJ InvestigationBy: Matt Fischer

The United States Department of Justice (DOJ) has the power to issue civil investigative demand (CIDs) when the DOJ has reason to believe that a person may be in possession of information relevant to a false claims investigation.  The DOJ is empowered to serve CIDs by the False Claims Act (FCA).  A CID is similar to a grand jury subpoena; however, it provides greater versatility in the use of the information obtained.  In addition to requiring the production of documents similar to a grand jury subpoena, CIDs demand other types of discovery responses and the information gathered may be shared between the civil and criminal sides of an investigation.  Given this flexibility and with the passage of the Fraud Enforcement and Recovery Act of 2009 (which changed the law to allow issuance of a CID without the personal signature of the Attorney General), the DOJ has substantially increased its use of CIDs in the realm of healthcare law enforcement.    

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