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The Connection Between Billing Fraud and Negligent Care at Nursing Homes in Florida

Some nursing home operators are ethical and do their best to provide quality care.  Others; however, do their best to bill Medicare and Medicaid as much as possible while providing minimal, and often, substandard care.

It is necessary that lawyers prosecuting nursing home negligence cases, understand the interplay between billing fraud and negligent care.

Every nursing home is required to prepare “Minimum Data Set” assessments of each resident’s functional capabilities and health problems.  “Care area assessments” are part of the process and are used to develop individual care plans for each resident.  MDS assessments are required for all nursing home residents and are to be prepared on admission and updated regularly.

MDS assessments are a double-edged sword for nursing homes.  Medicare reimburses nursing homes based on the complexity of each resident’s medical needs as identified in the MDS assessments prepared by the nursing home. Hence, there is the financial incentive to maximize the amount of care each resident requires.  Here is the catch –  after requesting payment for a heightened level of care, and after receiving such payment, sometimes nursing homes fail to provide that care, resulting in injury or death to the resident.

Understanding MDS assessments and the billing that results is essential to prosecuting nursing home negligence.  Without knowing how to prove that the nursing home itself determined that certain care was necessary, the nursing home is free to claim the care at issue was not required.

It is not uncommon for nursing homes that face elder abuse allegations in Florida to also be investigated for Medicare and Medicaid billing fraud. In southern Florida, a nursing home chain that runs seven nursing homes in the Miami area has been accused of providing substandard healthcare to its residents.  Just six months ago, that same chain agreed to pay $21.5 million to settle federal civil charges that it defrauded Medicare and Medicaid.

A media review of the company looked at U.S. Department of Health and Human Services (HHS) and Florida Agency for Health Care Administration (AHCA) records since 2012 and found 191 documented deficiencies at the nonprofit’s seven nursing homes in Miami-Dade County.  The same nursing home chain was hit with $24,820 in federal and state penalties for violations at three of its nursing homes in the Miami area.  The chain was also the subject of whistle-blower litigation that was settled earlier this year.

The cited deficiencies involving nursing home neglect included: allowing a resident’s wound to worsen for nearly three weeks without contacting the resident’s doctor; and improperly inserting a catheter into a resident causing injury and extensive bleeding.  We suspect that a lack of training (a cost saving measure) is most likely the ultimate cause of the catheter injury.

The Miami Herald’s investigative report “Neglected to Death” provides an eye opening look at the terrible reality of life and death for many residents in Florida’s nursing homes and assisted living facilities.

Our Jacksonville nursing home neglect lawyer represents clients and their families who have suffered injury or death due to negligent care.  Call us for a free consultation at (904) 632-0077.