Nursing Home Medicare Fraud Prosecutions
Nursing Home Medicare Fraud Prosecutions: Overview
Legal Framework
Nursing home Medicare fraud involves deceptive practices to obtain payments or benefits from Medicare or Medicaid unlawfully. Common violations include:
Billing for services not provided or unnecessary services
Upcoding — billing for more expensive services than provided
Kickbacks or illegal referral fees
Falsifying patient records
Prosecutions often involve violations of:
The False Claims Act (FCA) — 31 U.S.C. §§ 3729–3733
Health Care Fraud Statute — 18 U.S.C. § 1347
Anti-Kickback Statute — 42 U.S.C. § 1320a-7b(b)
Civil Monetary Penalties Law
Penalties include fines, restitution, exclusion from Medicare programs, and imprisonment.
Key Case Law and Examples
1. United States ex rel. Escobar v. Universal Health Services, Inc. (2016)
Facts:
Relators alleged Universal Health Services billed Medicare for services that did not comply with Medicare’s conditions of participation, specifically substandard care at nursing facilities.
Legal Issues:
Whether submitting claims with implied false certifications constituted a false claim under the FCA.
The scope of materiality in False Claims Act cases.
Ruling:
The Supreme Court ruled that claims could be considered false if they violated a material condition of payment, emphasizing the importance of materiality in FCA liability.
Significance:
This case refined FCA standards and has been influential in nursing home fraud prosecutions, making it easier to pursue claims for billing that violates regulatory standards.
2. United States v. Genesis Health Ventures, Inc. (2008)
Facts:
Genesis was accused of submitting false claims to Medicare for unnecessary rehabilitation therapy services at nursing homes.
Legal Issues:
Were therapy services medically necessary or were they used solely for increased billing?
Evidence of deliberate fraud vs. poor clinical judgment.
Ruling:
The company entered into a settlement paying millions in fines. The government demonstrated that inflated billing was systemic, not accidental.
Significance:
This case set a precedent for pursuing large nursing home operators for systematic billing fraud related to unnecessary therapy.
3. United States v. Jeffrey Balducci (2014)
Facts:
Balducci, an administrator of a nursing home, was prosecuted for submitting false claims to Medicare for services never rendered and altering patient records.
Legal Issues:
Evidence needed to prove knowing submission of false claims.
Impact of falsified documentation in Medicare fraud.
Ruling:
Balducci was convicted on multiple counts of health care fraud and sentenced to prison. The court emphasized that falsifying records to justify Medicare claims constitutes a serious offense.
Significance:
This case reinforced that fraudulent documentation is a key element in proving Medicare fraud in nursing homes.
4. United States v. Stephen Dawson (2017)
Facts:
Dawson, a nursing home owner, was charged with paying illegal kickbacks to patient recruiters to increase Medicare billings.
Legal Issues:
Violation of the Anti-Kickback Statute.
Proving intent to induce referrals in exchange for kickbacks.
Ruling:
Dawson was convicted, with the court holding that kickbacks distorted medical decision-making and increased improper Medicare spending.
Significance:
The case highlighted enforcement against illegal referral schemes in nursing home Medicare fraud.
5. United States ex rel. Wilkins v. United Health Group (2018)
Facts:
A whistleblower alleged that United Health Group’s subsidiary systematically billed Medicare for services that did not meet regulatory standards in nursing facilities.
Legal Issues:
Use of whistleblower (qui tam) actions under the False Claims Act.
Corporate liability for nursing home billing fraud.
Ruling:
The government reached a substantial settlement, affirming the role of whistleblowers in exposing fraud.
Significance:
This case showcased the power of whistleblower lawsuits in detecting and prosecuting Medicare fraud in nursing homes.
Summary & Key Legal Points
Nursing home Medicare fraud prosecutions rely heavily on the False Claims Act and Health Care Fraud statutes.
Fraud often involves billing for unnecessary or fictitious services, upcoding, and falsifying records.
Kickbacks to referral sources are a major focus under the Anti-Kickback Statute.
Whistleblowers play a critical role in uncovering systemic fraud through qui tam suits.
Courts emphasize materiality of false claims, intentional misconduct, and the impact on government healthcare programs.
Penalties include heavy fines, prison sentences, and exclusion from Medicare/Medicaid programs.
RELATED Blog
0 comments