All Medicare certified SNFs are required to conduct assessments on residents using a standardized assessment tool, called the Minimum Data Set (MDS), and categorizes residents into major categories. Using the Resource Utilization Group (RUG)tool , a computer program converts resident specific assessment data into a case mix classification. In classifying patients into groups based upon their clinical and functional characteristics, the grouper further subdivides each of the categories, resulting in specific patient RUGs.
Nolan Auerbach & White are experienced Whistleblower Healthcare Fraud Lawyers.
For each of the RUGs, the Medicare SNF per diem payment is calculated as the sum of three parts: the nursing component, the therapy component, and the non-case mix component. Under the nursing and therapy components of the payment rate, each of the RUGs carries a uniquely assigned relative weight factor. This relative weight factor, or case mix index, represents a relative index or resource consumption. Resource-intensive patients are assigned to a RUG that carries a higher relative weight factor. This RUG-specific relative weight factor is multiplied by the applicable nursing and therapy base rates (which vary depending on whether the SNF is urban or rural) to develop the nursing and therapy components of the per diem payment rate. These two components are then added to the non-case mix adjusted component, resulting in the total PPS per diem payment rate.
For a SNF admission to be covered under Medicare and most other Government Healthcare Programs, the beneficiary must have a qualifying hospital stay (meaning an inpatient hospital stay), of not less than three consecutive days before the beneficiary is discharged from the hospital. The beneficiary must enter the SNF within 30 days after discharge from the hospital or within such time as it would be medically appropriate to begin an active course of treatment, where the individual’s condition is such that SNF care would not be medically appropriate within 30 days after discharge from a hospital. The skilled services must be for a medical condition that was either treated during the qualifying three day hospital stay, or started while the beneficiary was already receiving covered SNF care. Additionally, an individual shall be deemed not to have been discharged from a SNF, if within 30 days after discharge from a SNF, the individual is again admitted to the same or a different SNF.
Skilled Nursing Facility Fraud can take various forms. Qui tam lawsuits often arise from widespread and systematically upcoded RUG rates, and/or the provision of lack of medically necessary skilled nursing or therapy services.
Kathleen Hawkins, RN MSN, had been employed by Defendant, Catholic Healthcare West (CHW) for approximately 6 years when she decided she had had enough of trying to change the hospital system from within.
CHW, a California not-for-profit corporation that operated hospitals in California, Arizona, and Nevada, was at the time the eighth largest hospital system in the nation and the largest not-for-profit hospital provider in California.
Joe Strom contacted us in 2005. We were very grateful that he did. We immediately formed an all-star legal team and a process to stop a very harmful pharmaceutical marketing strategy. It was this process we set into motion that ultimately returned hundreds of millions of dollars to the U.S. Treasury, and a portion of that, very well-deserved, into Joe’s bank account.
Joe told us a very troubling story about the off-label promotion of a pharmaceutical drug for patients who already suffered from chronic heart failure.
Bruce Moilan was a seasoned hospital systems expert by the time he contacted our Firm. At the time he decided to file his qui tam lawsuit, he was employed by South Texas Health System as a System Director for Materials Management. In this position, he oversaw $24 million in annual purchases of supplies and equipment and helped determine budget, reduction and cost analysis throughout the contract bidding and negotiations process. His job was to insure proper implementation for purchasing, receiving and management of inventory, for McAllen Hospitals, L.P.