Medicare Fraud at Skilled Nursing Facilities

Skilled nursing facilities are institutions that provide rehabilitation, medical, and nursing services for patients on a short or long-term basis. Under the Social Security Act, these types of services are covered by Medicare if they are medically necessary. Unfortunately, some skilled nursing facilities and nursing homes put profits above the health and safety of patients and residents. In some cases, they even commit insurance fraud. If you suspect that a skilled nursing facility is committing Medicare fraud, contact a Boston whistleblower law firm today.

$1 Billion Medicare Scam at Miami SNF Chain

In the largest health care fraud case in U.S. history, three Florida health care execs were recently charged by the Justice Department for their part in a $1 billion Medicare scam. Philip Esformes, the owner of a skilled nursing chain with more than 30 Miami-area facilities is charged with fraudulent activity against Medicare. According to the recently released 34-page indictment, Esformes conspired with two other people to provide medically unnecessary services and treatments to patients. The indictment also alleges that the trio received kickbacks for referring patients to other health care providers. To conceal their illegal actions, many of the kickbacks were paid in cash or disguised as charitable donations.

Medically-necessary admission to a skilled nursing facility is generally covered by Medicare and other government health care programs. However, several qualifying circumstances must be present to obtain reimbursement. If these requirements are not met, or the facility bills for treatment that is not medically necessary, the facility may be guilty of Medicare fraud.

RUG Upcoding

There is another common form of Medicare fraud in skilled nursing facilities: RUG upcoding. Using information provided by the facility, Medicare categorizes each patient into one of seven categories using a program called the RUG III Grouper. The assigned category is directly related to the per diem Medicare payment received by the facility. Unfortunately, some facilities falsify reported information so that Medicare places the patient in a high-paying category.

Federal False Claims Act

If you are aware of fraudulent activity in a skilled nursing facility or nursing home, you should report this information to a Boston whistleblower attorney immediately. As this type of fraud is a violation of the False Claims Act, whistleblowers who come forward with information that leads to financial recovery are often rewarded with substantial sums of money. These rewards act as an incentive to encourage individuals to report fraud and abuse against the government. Whistleblower compensation is generally a percentage of the recovered funds. Considering that some fraud cases recover tens of millions of dollars, whistleblower compensation can be quite significant. 

Altman & Altman, LLP – Boston’s Premier Whistleblower Law Firm

If you have unique information about fraudulent activity, contact the legal team at Altman & Altman, LLP today. Our skilled attorneys have more than 50 years’ experience protecting the rights of individuals, families, and workers across Massachusetts. We understand the complex nature of whistleblower cases; people are often hesitant to come forward out of fear of retaliation or losing a job. However, there are many protections available to whistleblowers. Our skilled lawyers will analyze the details of your case before moving forward with a legal strategy, and we will make sure you understand your rights and options.  If you suspect fraud, we can help. Whistleblower rewards can be quite substantial; we will help you get the compensation you deserve. Contact Altman & Altman, LLP today for a free and confidential consultation about your case.




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