The Department of Justice (DOJ) will continue to aggressively investigate skilled nursing facility fraud under President Trump, according to Bloomberg BNA’s legal, tax and compliance site.
The new administration will likely preserve several policies held over from the Obama era, which include the use of data-analysis in investigations. This analysis is culled from data mining, a method of finding patterns in large amounts of data that may help detect fraud. Data mining software tools can predict future behavior based on the knowledge of past events. It’s used to help investigators identify and analyze billing patterns and Medicare criminals, and stop fraudulent claims before they’re paid.
In 2015, Deputy Attorney General Sally Quillian Yates proposed The Yates Plan, which holds more individuals – as opposed to corporations — responsible in fraud cases. These offenders can range from nursing home management executives to facility personnel. Civil and criminal prosecutors will also commit to increased cooperation in bringing these individuals to justice The goal of this plan is to encourage more self-regulation and self-disclosure. The government provided 20 specific examples of Medicare claims for what it said were unnecessary therapy services administered to patients.
In September 2016, a settlement cost a skilled nursing facility $28.5 million due to allegations of unnecessary billings at its locations.
Owners and operators of three Miami skilled nursing facilities were charged criminally in a $1 billion nursing home fraud scheme. According to the DOJ, this was “the largest single criminal health-care case ever brought against individuals” The owner, a hospital administrator and a physician’s assistant were charged in an indictment with conspiracy, money laundering and health-care fraud, according to the U.S. Attorney’s office in Miami.
As part of the DOJ’s Elder Justice Initiative, a top priority will be combating fraud in post-acute care. The department’s ten regional nursing home task forces will focus on nursing homes that provide “grossly substandard” care. This plan includes members of the U.S. Attorney’s offices, state Medicaid Fraud Control Units, state and local prosecutors offices, the Department of Health and Human Services, state Adult Protective Services agencies, long-term-care ombudsman programs and law enforcement.
The goal: to resolve concerns about under-performing and fraudulent nursing homes in a timely manner.
“All too often we have found nursing home owners or operators who put their own economic gain before the needs of their residents,” said Acting Associate Attorney General Stuart F. Delery. “These task forces will help ensure that we are working closely with all relevant parties to protect the elderly.”
Also on the DOJ radar in the new administration: fraud in the pharmaceutical and medical device industries.