The Medicare program is a vital support system for seniors in the United States. The health care program ensures that all elderly community members have access to the care they need to deal with the medical ailments they face. Of course, as with all insurance coverage, there are various rules which dictate when one qualifies and what specific care is paid for under the program.
For example, there remains much confusion regarding the long-term care that is or is not provided to Medicare recipients. Most notably, it is Medicaid, not Medicare, that provides long-term nursing home coverage. If a senior reaches the point where it is not safe for them to live in their own home, they usually need to have Medicaid coverage to receive federal support for a move into a nursing home.
But that is not to say that Medicare provides zero payments for nursing home stays. Instead, Medicare’s coverage is more limited, intended only to pay for rehabilitative stays, usually only lasting a few months. These rehab stays are thought of as connected to actual medical care as opposed to the more permanent living arrangements of some in long-term care facilities.
Nursing Homes & Medical Billing
All of this means, however, that nationwide there are billions of dollars spent every year on nursing home connected care via the Medicare and Medicaid programs. Unfortunately, this large money stream is often abused, with many cases of companies engaging in questionable, or outright illegal, practices in order to boost their bottom line.
The Mercury News recently profiled one such case. According to allegations made by federal officials (spurred by whistleblower lawsuits), one large nursing home companies engaged in illegal Medicare billing practices for years at various facilities across the country. The illegal conduct apparently took the form of billing for unnecessary speech, occupational, and physical therapies of nursing home residents. In some cases, claim investigators, residents in rehabilitation stays at nursing homes were kept at the facility longer than necessary, solely so that more unnecessary therapies could be provided and then billed to Medicare.
According to reports, officials with the nursing home company agreed to settle the matter. Without technically admitting guilt, the company will pay $48 million to end the case. The U.S. Attorney working on the situation explained later, “"This settlement—one of the largest of its kind in United States history—demonstrates our commitment to protecting taxpayers who fund important programs that benefit millions of Americans, but don't want to see their hard-earned money wasted on fraud or abuse."
These particular lawsuits, like so many similar, were initiated by private individuals who used to work for the company in question. The False Claims Act is a federal law that allows individual with knowledge of potential fraud to come forward and seek accountability within the legal system for redress. As an incentive, those private individuals are then entitled to a portion of the recovered amount, often amounting to millions of dollars.
For help on these issues, consider contacting a whistleblower attorney today.
See Other Blog Posts:
Seniors Challenge Questionable Medical Bills
Criminal Complaint Filed in Unnecessary Tracheotomy Case