In the current system, Medicare pays nursing homes a daily rate for a resident’s stay based on how much therapy they receive. Residents who receive “ultrahigh” therapy, at least 720 minutes per week, generate the biggest payouts for nursing homes. Medicare initiated this payment system in 1998, and nursing homes have caught on to how to bilk the system, billing for increasing therapy levels even for residents in extremely poor health.
Our team of nursing home abuse lawyers examines how this trend in ultrahigh therapy is contributing to the negligence, abuse, and mistreatment of residents.
A piece in the Wall Street Journal recently profiled a man in California who spent 21 days in a nursing home. The resident, Jack Furumura, was 96-years-old and lost more than five pounds during his stay from severe dehydration and malnourishment. Despite his poor health, dementia, and age, nursing home staff forced him to endure two hours or more of physical and occupational therapy per day. The nursing home billed Medicare top dollar for his ultrahigh therapy, racking up $13,468 during his 21-day stay.
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Furumura left the facility for the hospital and then his daughter’s home, where he passed away a few weeks after leaving the nursing home. His family could not imagine him participating in therapy for two hours each day in his condition, and were shocked when they reviewed his nursing home records.
Of course, occupational, speech, and physical therapy are important services in nursing homes. Problems occur, however, when residents have previously declined therapy, have been unresponsive to treatments, or when benefits are not clear or likely. The Medicare reimbursement system rewards ultrahigh care, however, so managers often pressure caregivers to reach the 720 minutes per week goal, to make the most money.
And the problem is only increasing. In 2002, about 7% of all days billed to Medicare included ultrahigh therapy sessions. By 2013, 54% of all days billed were for ultrahigh therapy. Some chains have even higher rates: Genesis Healthcare Corp., one of the largest nursing home providers in the country, billed for ultrahigh therapy in 58% of days in 2013 – compared to 2002, when it billed for ultrahigh care on just 8% of days. Kindred Helathcare had nearly identical percentages.
HCR Manorcare Sued for Unnecessary Therapies
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HCR Manorcare, however, billed for ultrahigh care for 68% of days in 2013. This led to three federal lawsuits in April 2015, when the Department of Justice (DOJ) sued HCR Manorcare for knowing and routinely billing Medicare for therapies that were not necessary or reasonable. Manorcare operates more than 280 nursing homes in 30 states.
The Principal Deputy Assistant Attorney General stated that the DOJ is committed to holding companies who pressure employees to provide unnecessary care accountable for their illegal and immoral practices. He further stated that companies engage in this behavior solely to increase their own profits at the expense of federal healthcare programs.
Manorcare is accused of setting billing goals designed to significantly increase profits without consideration of residents’ actual care needs. The company is also accused of threatening to terminate managers and therapists if they failed to administer these therapies.
The lawsuits were filed as qui tam, or whistleblower claims, which allow private citizens to sue on behalf of the government for false claims submitted to the government. If the lawsuit is successful, the citizen is then entitled to a significant portion of the recovery. Healthcare is an industry wrought with fraud, and the government relies heavily on whistleblowers to expose billing schemes like HCR Manorcare’s.
Another nursing home operator, Ensign Group, recently paid $48 million for unnecessary therapy billed to Medicare. This lawsuit was also the result of a claim filed by a pair of whistleblowers. The two former Ensign employees will receive between $7.2 and $14.4 million from the settlement.
Since 2009, the DOJ has recovered more than $24 billion through whistleblower cases, over $15 billion of which stemming from fraud against healthcare programs. Federal laws prevent whistleblowers from being fired or retaliated against if they report their employer, and in fact, the most common whistleblowers are current or former employees and subcontractors.
We provide free case reviews to anyone concerned about potential nursing home fraud, abuse, mistreatment or negligence.