Skilled Nursing Facility Fraud
Serving Clients Nationwide
Medicare and other government healthcare programs cover medically necessary admission to a skilled nursing facility (SNF) within 30 days of a covered inpatient hospital stay lasting no less than three days. However, in order for the SNF services to be covered, each of the qualifying requirements must be met and documented. For example, the patient must be receiving SNF care for a condition or injury that was treated or began during the qualifying inpatient hospital stay. Billing Medicare for SNF treatment that is not medically necessary or does not meet the established qualifications for coverage can be considered Medicare fraud under the False Claims Act.
Another form of Medicare fraud in skilled nursing facilities is RUG upcoding. Medicare-certified skilled nursing facilities must assess residents’ needs using the Minimum Data Set (MDS) tool. Using MDS information, Medicare then assigns one of seven categories to each patient using a computer program called the RUG III Grouper. Each of the categories has a different relative weight factor, which is used as a multiplier in determining the per diem Medicare payment that the SNF receives for that patient. Therefore, SNFs have substantial incentive to falsify or alter MDS information in order to move the patient into a higher-paying RUG category.
Becoming a Whistleblower on SNF Fraud
If you have knowledge of RUG upcoding or billing Medicare for non-covered admissions at a skilled nursing facility, your knowledge could enable you to become a whistleblower in a qui tam lawsuit against the SNF. Fraudulent Medicare billing at SNFs is a violation of the False Claims Act, which allows for generous whistleblower rewards for individuals who come forward with successful qui tam actions. These rewards are compensation for the public service whistleblowers perform in helping the government recover funds lost to fraud and abuse.
Representing whistleblowers nationwide for fifteen years, the qui tam attorneys at Kenney & McCafferty have the investigative experience needed to handle complex Medicare fraud cases as well as the trial experience needed to secure a positive outcome. In addition, Kenney & McCafferty will work to protect your rights under the whistleblower protection provisions of the False Claims Act.
If you have knowledge of a fraud or false claim against the government, please contact our qui tam lawyers today. Kenney & McCafferty attorneys will consult with you about your case, without obligation. All communications with Kenney & McCafferty attorneys during these consultation services are confidential and protected by the attorney-client privilege.