Report on Medicare Compliance 29, no. 7 (February 24, 2020)
◆ Guardian Elder Care Holdings Inc., which operates more than 50 skilled nursing facilities (SNFs) in Pennsylvania, Ohio and West Virginia, and its related companies will pay $15.46 million to settle false claims allegations over medically unnecessary rehabilitation therapy, the Department of Justice (DOJ) said Feb. 19.[1] According to the settlement, DOJ alleged the SNFs provided therapy services to Medicare and Federal Employee Health Benefit Program beneficiaries at the highest resource utilization group level (ultra high) when that level wasn’t medically necessary from Jan. 1, 2011, to Dec. 31, 2017. The false claims lawsuit was set in motion by two former employees turned whistleblowers. “Relators generally alleged that Guardian Elder Care pressured its rehabilitation therapists to provide therapy services to meet financial targets and maximize revenue, without regard to clinical need,” the settlement states. “For example, certain patients suffered from dementia and allegedly did not need or want rehabilitation therapy, but Guardian Elder Care allegedly pressured therapists to provide them with therapy anyway to meet revenue goals.” The settlement also says Guardian disclosed to the government on Sept. 26, 2018, and Oct. 12, 2018, that it provided certain services to Medicare beneficiaries through two people who were excluded from Medicare, one who worked at a Guardian facility for five days and the other who worked part-time at a Guardian facility for eight years. In a statement, Patricia McGillan, Guardian Elder Care’s chief compliance officer, said “Resident care remains our first priority and we are committed to meeting our obligations under this agreement. We are confident that Guardian’s Corporate Compliance Program advocates for our patients, their families and caregivers.”
◆ CMS on Feb. 20 proposed a regulation[2] that would extend the Comprehensive Care for Joint Replacement (CJR) Model for three years and make some changes. For one thing, the rule would include outpatient knee and hip replacements in the definition of a CJR episode.
◆ The HHS Office of Inspector General has updated its Work Plan.[3]
◆ Palmetto GBA, the Medicare administrative contractor (MAC), has shifted gears on recoupment for post-acute care transfer (PACT) payment policy errors. The MAC said Feb. 7 that instead of recouping the entire MS-DRG or allowing hospitals to file adjusted claims for the per diem,“it’s re-adjusting all claims previously rejected with the appropriate discharge status code,” according to its website. In a Feb. 13 update, Palmetto added that the overpayments had been “adjusted and closed to zero…Revised demand letters based on the partial reduction from DRG to per diem payments will be issued at a later date.” The overpayments stem from PACT errors identified by the HHS Office of Inspector General in a November 2019 report. OIG found that Medicare overpaid acute-care hospitals $54.4 million, although it said “the total overpayment amount represented the difference between the amount of the full MS-DRG payments that were made and the amount that would have been paid if the per diem rates had been applied.”
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