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Skilled nursing facilities provide temporary care for people who need close medical attention following a serious injury or illness. Eligible Medicare recipients can receive coverage for their time in a skilled nursing facility as they transition from a hospital back to their homes. However, concerns about abuse in regard to these claims led the Centers for Medicare and Medicaid Services to institute what is called the Patient Driven Payment Model in order to assess the incidence of fraud. Now, the Office of the Inspector General (OIG) for the Department of Health and Human Services has completed an audit that shows rampant noncompliance by a leader among skilled nursing facility providers. 

According to its review, OIG determined that Pinnacle Multicare Nursing and Rehabilitation Center’s claims for skilled nursing services did not comply with Medicare requirements for nearly every sampled claim, resulting in excess payments of $1.1 million for services provided during calendar years 2020 and 2021. Based on the sample results, the report estimates that the overall amount of improperly distributed funds exceeds $30 million.  

OIG cited the following three main areas in which Pinnacle violated Medicare rules:

• Reviews of patient records show that the reimbursement code sent to Medicare was inappropriate in many cases.

• Some patients were in Pinnacle facilities despite the fact that their condition did not justify skilled nursing services.

• Claims submitted to Medicare lacked the proper documentation. 

Estimates say that the total amount of taxpayer funds lost to Medicare and Medicaid fraud each year is greater than $100 billion. Despite government efforts to curtail overpayments, even identifying a single case of misconduct can be a challenge. Assessing whether an individual patient actually needs to spend time in a skilled nursing facility or if the correct reimbursement code was applied demands access to records and possibly even a physical presence at the location. 

If you work for skilled nursing facility or any other type of healthcare provider, you might have noticed questionable actions, such as the misreporting of treatments or the dispensation of services that did not seem warranted by the patient’s condition. These could be signs of Medicare or Medicaid fraud. 

Kardell Law Group represents conscientious workers in the healthcare industry who report problems involving potential overpayments. Depending on the circumstances, you might be entitled to payment if you act a whistleblower. Contact us today if you think you’ve recognized misrepresentations related to government health benefits.