When an elderly loved one can no longer care for themselves, there are often difficult decisions that must be made. Even the most independent and lively seniors may begin to have trouble with independent living in their later years, and it often falls to their family to figure out how to best help them as they age. Nursing homes and assisted living facilities offer support to elderly individuals and peace of mind for their families.
When choosing a nursing home for a loved one, every effort is made to ensure that they are placed in a good facility. However, often unbeknownst to loved ones, some nursing homes participate in unethical practices for profit – otherwise known as nursing home fraud. The lawyers of Tycko & Zavareei LLP are here to help you fight back and report nursing home fraud in Indiana.
What is Nursing Home Fraud?
Nursing home fraud in Indiana usually targets insurance companies or government programs rather than individuals or families, which is part of the reason it often goes unnoticed. Most individuals in nursing homes are on either Medicare or VA benefits provided through the government rather than private insurance. Consequently, these programs are targeted most often by fraudulent nursing homes.
The primary goal of nursing home fraud is to increase the benefits or payouts that the nursing home receives from the government. This is done by lying about the resources being used by the nursing home in order to care for its residents, or even cutting corners on patient care in order to receive a higher payout from a government program. Taking advantage of senior citizens is unacceptable, and here at Tycko & Zavareei LLP, we do everything we can to put a stop to it.
Indiana Nursing Home Fraud Examples
There are several methods that a nursing home may use in order to fraudulently collect benefits from the government. Some of them involve being dishonest on paperwork, while others directly impact patient care and quality of life. Here are a few common strategies used in nursing home fraud:
- Upcoding – when the provider or billing office enters an incorrect billing code for the service received, often for a similar service that is higher in cost.
- Unbundling – when medical services that are normally billed together are billed separately, allowing the provider to collect higher reimbursement than if these services were billed together under one code.
- Not providing residents with a comprehensive care plan – deliberately failing to provide residents with a plan outlining their medications, procedures, physical therapy, and other necessary care in order to “sneak in” more services that the resident does not actually need or otherwise deviate from their care plan.
- RUG fraud – placing residents into a higher resource utilization group than necessary in order to collect more reimbursement.
What is a RUG in Nursing Homes?
A resource utilization group, or RUG, is a classification system used to determine the reimbursement that a nursing home will receive for each resident. Nursing home residents undergo a 108-question assessment administered by skilled facility staff and are then classified into RUGs according to their needs and the level of care they require.
A resident may be placed into one of seven categories, ranging from low to high support needs. The higher a resident’s RUG category is, the more reimbursement funds the facility receives from Medicare. Skilled nursing home facilities seeking to defraud the government may do so by “inflating” a patient’s RUG score, therefore placing them in a higher category than they really need in order to collect a higher amount from Medicare.
Nursing Home Fraud Cases in Indiana
In 2018, a community hospital in Johnson County, Indiana was exposed for allegedly participating in a kickback scheme with Community Health Network. The public hospital allegedly paid millions of dollars in kickbacks to CHN in exchange for referrals to Johnson Memorial nursing homes, which many have said provided subpar care to their residents. The nursing homes were reportedly using the additional patients they received via referrals from CHN to increase their federal Medicaid funding.
This information came to light only after the former CFO of Community Health Network, Thomas Fischer, filed a whistleblower lawsuit. The federal government has not yet taken action on these allegations, though they have reportedly begun investigating other claims made by Fischer.
Contact Our Nursing Home Fraud Lawyers in Indiana
Coming forward about nursing home fraud may seem difficult or intimidating at first. However, the United States government relies on whistleblowers to disclose what they see and hear. Employees have the ability to notice patterns and suspicious behavior where the government cannot. When the government receives a bill for services covered by Medicare, they may not notice anything suspicious. However, a nursing home staff member who submitted the bill may spot a service on that bill that they know the resident did not receive. Even small pieces of information may be helpful in prosecuting nursing home fraud.
Anyone who suspects fraudulent activity in an assisted living facility should speak with a nursing home fraud lawyer in Indiana. Reviewing your concerns with a lawyer is often the first step to seeking justice. Tycko & Zavareei LLP is here to help. If you have information about nursing home fraud in Indiana, contact us today to schedule a free case evaluation. If your case is successful, you may qualify for 15 to 30 percent of the amount recovered.
