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Skilled Nursing Fraud

Through an extension of the Medicare Part A Hospital benefit, Medicare offers limited coverage of post-hospital skilled nursing care for qualifying patients. See 42 U.S.C. § 1495i.  In order to qualify for coverage, a patient otherwise appropriate for Medicare must show a qualifying hospital stay of three or more days within the 30 days prior to entering the skilled nursing facility. A physician must order procedures for the patient that are appropriate to be performed only in a Skilled Nursing Facility (SNF), such as rehabilitative therapy, and must certify that the patient’s condition is such that he or she can practically be cared for only in a SNF. In so certifying, the physician must determine that the patient’s condition should improve or achieve stability in response to curative care. The SNF medical staff is required to write a plan of care for each skilled nursing patient based upon the individual’s needs and circumstances. Upon satisfaction of those requirements, Medicare will pay for 100 days of skilled nursing care per-patient per-illness period – though after the first 20 days a co-payment of 20% is required of the patient.  Once a patient qualifies, Medicare bears all expenses of the skilled nursing facility, including the patient’s custodial care and room and board (custodial care is not otherwise covered by Medicare). Typically, an SNF receives approximately $650 per day from Medicare for a qualifying skilled nursing patient.

Frohsin & Barger has identified and uncovered several types of fraud related to the SNF Benefit including:

  • Aggressively recruiting hospital patients who are not appropriate for skilled care, generally by obfuscating the nature of skilled care and emphasizing “free” custodial care;
  • “Skilling” patients who do not require or cannot benefit from physical, occupational, or speech therapy or other skilled care;
  • Billing for skilled care through Medicare and Medicaid for services that actually require no skill and are effectively custodial or intermediate maintenance care;
  • Creating improper relationships between SNFs and hospices, whereby patients are shuffled between benefits to increase billing, without regard to propriety or patient well-being;
  • Paying illegal kickbacks between SNFs and hospices for cross-referrals, particularly in the form of hospice nurses providing free services to SNF patients.

To report Skilled Nursing Fraud, contact Frohsin & Barger.

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