OIG fraud report portends more challenges for skilled nursing

An yearly report outlining point out fraud manage activities in the nation’s Medicaid amenities portends a challenging year forward for nursing residences.

There were being extra than 1,000 open investigations into patient abuse or neglect at experienced nursing facilities at the conclude of 2022, disclosed the Overall health and Human Companies Place of work of Inspector General report issued Wednesday. That was far more than in any other care placing. With 311 scenarios, nursing households also led in open fraud investigations between inpatient and residential companies.

This is “not an isolated blip on the radar of MFCU fraud-preventing attempts,” a person legal expert told McKnight’s Long-Phrase Care News Thursday. Vendors ought to hope much more enforcement action in 2023 from Medicaid Fraud Handle Models as numerous state and federal enforcement entities proceed to ramp back again up from early COVID-era delays.

“In phrases of wherever enforcement methods are probable to be devoted, agencies normally prioritize circumstances wherever resident damage has occurred or there are crystal clear challenges to the wellbeing, basic safety and nicely-staying of facility citizens. I have no question that similar forms of worries will generate enforcement likely ahead,” stated Jesse Berg, a partner with Lathrop GPM’s Minneapolis business.

“MFCUs and other enforcement organizations will also carry on to focus on reimbursement fears and cases of incorrect billing by providers. This can be overwhelming for vendors mainly because the complexity associated with Medicaid and Medicare payment regulations.”

Berg also pointed out that the Untrue Promises Act and its requirement that nursing facilities report and return overpayments inside 60-times of identification “means the stakes are very large for acquiring points appropriate.”

Wrong Claims instances are not below the jurisdiction of point out and territorial-level Medicaid fraud units. But the Justice Department’s own renewed commitment to article-COVID fraud enforcement and the Administration’s continued scrutiny of nursing homes provides to heightened provider concern about overzealous prosecutions and civil satisfies.

Overall in 2022, the Medicaid fraud models won 1,327 convictions, 381 for affected individual abuse and 946 for fraud. Convictions for client abuse or neglect involved two service provider forms much more than any other folks: nurse’s aides and nurses or medical professional assistants.

The units also gained 553 civil judgments final 12 months. On the legal aspect, they recovered $416 million, with a different $641 million taken on the civil aspect.

Full convictions in Medicaid fraud unit instances ongoing to enhance from fiscal 2020, but remained lower than in fiscal 2019. 

Skilled nursing companies escaped some of the negativity of past stories, with no important instances creating the OIG’s narrative. Instead, the OIG mentioned a key earn by the Texas MFCU versus a hospice facility CEO, who was convicted of defrauding the Medicare and Medicaid programs. 

Amid other missteps, the defendant billed Medicare and Medicaid for hospice expert services that had been not provided, not directed by a clinical qualified and furnished to clients not suitable for hospice care. In addition, the defendant utilized blank, pre-signed managed substance prescriptions to distribute medication without having physician enter.