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A Mission Viejo company called Ensign Group Inc. – responsible for operating different nursing homes in several different states – recently agreed to pay $48 million in order to settle allegations that the company billed Medicare for therapy sessions that either never took place or were unnecessary.
This came after whistle-blower lawsuits involving two former Ensign Group therapists accused the company. While these lawsuits date back to 2006, according to the prosecutor, the Medicare fraud occurred between 1999 and 2011.
The company refuses to admit fault
According to the assistant attorney general for the Justice Department’s civil division, Stuart F. Delery, the Justice Department aims to hold those facilities that place their own financial interests above the needs of their patients accountable. At the same time, the Ensign Group denied any and all wrongdoing. Instead, it claimed that it would be easier to resolve the allegations through settling than to go through the expense and uncertainty of protracted litigation.
Part of the problem
According to one of the lawsuits, the Ensign Group encouraged fraudulent billing by rewarding employees for reaching certain ‘spectacular goals’ and setting unreasonable goals for Medicare billing. According to the lawyer representing one of the whistleblowers, the company put pressure on administrators to achieve certain goals that were not realistically accessible unless the company cheated Medicare.
Employees performed therapy for longer periods than patients needed or billed at higher rates than was justified, all in order to reach the incentive goals. Some of the benefits included an all-expense paid trip to Alaska, Hawaii, and other popular destinations. Despite this being one the largest Medicare fraud cases against nursing home chains in history, it highlights another problem, the commercialization of personal care. When these large companies take over nursing homes and focus on turning a profit before worrying about the health of its patients, everyone involved in the process loses.
Why this is such a problem
With healthcare costs being such a controversial topic in recent elections, it may be easy to overlook that the healthcare costs throughout the nation are more than $2.7 trillion every year and are still rising. These costs include a significant amount of Medicare fraud, including assisted living facility Medicare fraud and nursing home Medicare fraud.
As more and more people are eligible for Medicare and more people move into assisted living facilities and nursing homes, these numbers are expected to rise. Because the number of Medicare eligible recipients is growing, more people are going to pay for their healthcare through Medicare; this includes medical equipment, pharmacies, physical therapy, home health care, hospice, and nursing homes.
Remember to speak out
Unfortunately, it is far too profitable and easy to increase the income from Medicare by using fraudulent billing practices. This is about more than just offering unnecessary services or charging for services that were never performed, it may also include falsely certifying goods not delivered, double billing for services, illegal kickbacks, and manipulation of outlier payments to Medicare. Ultimately, the United States taxpayers are paying billions of dollars each year for Medicare fraud. Just one more reason it is always important to seek qualified legal counsel and speak out if you notice something inappropriate.