Legal Services for Nursing Homes
What are common criminal charges against Nursing Homes?
Nursing homes have come under a high level of scrutiny from the federal government in recent years especially because Medicaid and Medicare help to fund most nursing homes. Nursing home facilities provide 24-hour observation and care to their patients so the bills they end up submitting to Medicaid end up being quite extensive which could lead to the ability to make changes to bills.
Health care fraud and False Claims Act charges are very commonly prosecuted by the Department of Justice against owners and employees of Nursing Homes when they improperly billed Medicare and Medicaid for their services. In addition to these federal crimes, you may face state specific crimes if you fail to provide a certain level of care to your patients.
What practices make my nursing home susceptible to these charges?
When your nursing home is preparing bills to be submitted for insurance companies, you need to make sure that the bills are proper, meaning they are billing for work done and not anything else, and you need to make sure that you are not trying to cheat the system out of money. There are several schemes that fall under health care fraud as outlined in our health care fraud article.
How do the actions of the nursing home I work at impact me?
Whenever you work at a facility that is actively committing health care fraud or submitting false claims, you may also face charges if you are participating in the schemes. It is important as a worker at any nursing home to make sure you are in compliance with the law because if you actively participate in a scheme to defraud an insurance company or the federal government, you may face conspiracy charges as well as fraud charges.
If your company becomes under investigation, you should contact an attorney to find out what liability you may have for any crimes committed. You should try to avoid practicing in any practices that you feel may be in violation of the law and discuss with a lawyer if you want to disclose any illegal practices.
What is “Health Care Fraud?”
Health care fraud involves knowingly defrauding an insurance company in an attempt to make more money than what is owed for the services you provide. Health Care Fraud 18 U.S. Code § 1347 makes it illegal to attempt to defraud any insurance company, and several schemes fall under this, such as double billing, billing for services not rendered, or receiving kickbacks.
What is a charge under the False Claims Act?
It is very common for nursing homes to be charged with violating the False Claims Act because most of their payments go through Medicare and Medicaid. The False Claims Act provides criminal and civil liability for knowingly making submitting false records or claims to the government.
The violation of the False Claims Act means either knowingly or unknowingly being held liable under this law. This law is extremely broad and covers several forms of false records. This means that you may be charged even if you don’t know your nursing home is committing this type of fraud, but you should have.
What are the penalties under these laws?
The offense of Health Care Fraud comes with a sentence that includes jail time up to 10 years and criminal fines up to $250,000. If any of your patients are injured your sentence can increase to 20 years, and if someone dies, you may face life in prison. If you are not proving the proper care for your patients and you are billing for that care, you may face a long sentence.
The civil penalty under the False Claims Act is $11,000 for
each false claim plus up to three times the damages to the government for the
claim. The criminal liability under this law can be assessed only if someone
knowingly makes a false claim, and the criminal punishment is a fine up to
$250,000 and up to 5 years imprisonment.
Why might the government initiate a fraud investigation?
There are several nursing homes across the country, and most of the nursing homes are largely funded through the federal government. Because there is such a high cost on the government, they investigate cases of fraud quite often. An investigation may begin when patients or loved ones report the facility for inadequate care. Another common way investigations begin against nursing homes is through a whistleblower lawsuit.
What are whistleblower lawsuits?
One of the more common ways that the federal government is tipped off of fraud is through whistleblowers filling a qui tam lawsuit. Whistleblowers are private citizens with insider information that file a lawsuit against a medical professional or group for fraud related activities. If there is a successful conviction of fraud the whistleblower may get between 15-30% of all money recovered by the federal government in the lawsuit.
These suits are important for you to defend against because they may lead to criminal charges being filed against you in conjunction with the lawsuit. If your nursing home is practicing health care fraud, whistleblowers might be incentivized with the potential of a large payday to disclose information to the federal government.
What to do after a charge has been filed?
If you are charged with any crime in relation to your practice at a nursing home, your first step should be to contact an attorney. Our attorneys have experience defending against criminal health care charges and will be able to work to defend you and your nursing home from any charges.
Once charges are pressed the next step is a grand jury hearing where the grand jury will determine if there is enough evidence to indict. If you are indicted there is a chance your case may end up in a jury trial.
What to do to fight these charges?
When you are charged with any fraud-related charges, there are certain defenses that we may be able to raise on your behalf. These defenses might help to mitigate any potential sentence you may face or even have the charges dismissed against you. During each step of the investigation, you should work with your attorney to defeat these charges by raising various defenses.
Defenses to fraud in nursing homes
When you work at a nursing home that is committing fraud, you may have the defense that you were not involved in any of the fraudulent activities. You must keep detailed and accurate records of all of the work you perform. If you were involved and had no knowledge or no reasonable understanding of the fraud you may also raise this as a defense.
What if I had no knowledge of the crime?
When you are convicted of any crime, there needs to be knowledge of the crime committed or at a minimum you need to purposefully not seek the truth of a matter. When you mistakenly overbill insurance, you may have the defense that any violation was not done knowingly. This type of defense may work for criminal charges, but you still may face liability under the False Claims Act.
Cases against Nursing Homes for fraud.
Fraud charges against nursing homes are on the rise with the federal government coming down in an attempt to make back the money. The amount of money spent on nursing homes is extremely high, so there is a chance for the federal government to make back quite a bit of money if they find an instance of fraud.
$133 million dollar recovered from a Nursing Home Fraud Case
Settlements for health care fraud can get quite expensive. In 2016 RehabCare one of the largest nursing home providers had to pay out $133 million dollars for a fraudulent scheme that they put into place. These charges were civilly filed under the False claims act stating that they were billing Medicare fraudulently.
The company allegedly would bill for the highest level of therapy care while only providing a lower level of therapy. They would also alter and change numbers on their bills to bill for more hours and estimate and round numbers instead of giving exact values.
This suit was brought against the parent company of RehabCare as well as their subsidiary nursing facilities located in Massachusetts and New York. The charge here of false claims ended up costing the company a huge amount of money and listed the company as being part of a fraudulent scheme.
Nursing Home and Pharmacy Kickback Schemes
Kickback schemes are another way that nursing homes are fraudulently getting money from the federal government and getting payments from other practices. This type of fraud was seen against Omnicare which was providing nursing homes with an anti-epileptic drug at a reduced price in return for the nursing homes over prescribing this drug.
The charges for kickbacks against Omnicare ended up costing them about $124 million in total reimbursements. The thing that could happen with kickback schemes is that both the pharmaceutical company and the nursing home could get in trouble for their scheme and charge under the Anti-Kickback Statute.
Whistleblower leads to Texas Nursing home paying $5 million in restitution
One of the most common ways for nursing home claims to be brought forward is through a qui tam lawsuit, which is initiated when someone blows the whistle on a fraudulent practice. Health Services Management Inc. faced a qui tam lawsuit in 2017 which lead to them having to pay out $5 million for their fraudulent billing of Medicare and Medicaid.
The case was settled between the federal government and Health Services Management Inc. with no admissions of guilt, but they were allegedly billing for services that were never provided. They also were not providing services to their patients even if they were billing for those services.
In October of 2014, a worker at one of the facilities filled a qui tam lawsuit against the company. This lawsuit ended with the settlement of $5 million dollars, and a portion of that money would most likely be paid out to the whistleblower.
What should you do?
As an owner or employee of a nursing home, it is important to get ahead of any fraud claims. You should contact our experienced attorneys to help you through this process. We can represent you through each step of the case from investigation to a potential trial.