Healthcare fraud remains one of the most prevalent types of insurance fraud in the U.S. today, and two programs that perpetrators often target are Medicare and Medicaid. In nursing homes, residents are particularly vulnerable to financial abuse because of their cognitive issues, physical condition, and other health concerns. They rely on administrators and staff members to tend to their meals, personal care, medication, and other needs, but occasionally, some workers engage in questionable practices. When healthcare abuse and fraud in nursing homes occur, it is the elderly patients who ultimately suffer and get hurt. You must recognize signs of fraudulent acts so you can inform the proper authorities and protect your loved one.
Understanding Healthcare Abuse and Fraud
Fraud is any dishonest and deliberate act that an individual carries out with the knowledge that it will lead to an unauthorized benefit to someone not receiving the benefit. Meanwhile, abuse consists of actions that are not in line with accepted sound medical practices and may result in unnecessary costs or medical services. Healthcare abuse and fraud in nursing homes frequently involve unlawful or improper medical billing. Government programs, private insurers, and nursing home residents continually become victims of fraud despite the threat of criminal and civil liability for perpetrators.
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Laws About Healthcare Abuse and Fraud
Several federal laws preside over healthcare abuse and fraud cases. Various government agencies such as the Department of Health & Human Services Office of Inspector General (OIG) and the Department of Justice enforce the laws, and those they find violating them may face civil fines and criminal penalties. The following are some essential abuse and fraud laws.
This forbids making willful payments in exchange for generating business related to Federal health care programs or for rewarding patient referrals. It is a crime to pay for referrals when they involve services, supplies, or medications for Medicaid or Medicare patients. Aside from cash, payment can be in the form of free rent, expensive meals, and lavish hotel stays.
False Claims Act
It is unlawful to hand in a claim for payment to Medicaid or Medicare, which an individual knows or should know is fraudulent or false. This act aims to protect the government from overcharges or poor-quality goods or services.
Physician Self-Referral Law
It is illegal for physicians to refer their patients to receive Medicaid or Medicare health services from entities that have a financial relationship with the physicians or their immediate family members. Investment interests, ownership, and compensation arrangements are examples of financial relationships.
Criminal Health Care Fraud Statute
This forbids healthcare workers from knowing and willfully executing a plan intending to defraud a healthcare program or to receive payment for healthcare services, benefits, or items. Punishment for offenders includes fines and prison time.
How Nursing Home Abuse and Fraud Occur
Sadly, some corrupt nursing homes take advantage of elderly or sick residents. Financial abuse can take place when administrators or staff members manipulate residents’ finances to control them or misappropriate their funds. The most common types of fraud involve Medicaid and Medicare programs and can include the following practices.
A False Claims Act case typically arises when a healthcare provider charges Medicaid or Medicare for medications or services that they did not provide. Another instance would be charging for drugs or services at inflated prices.
Unnecessary Medical Procedures
There are times when nursing homes arrange for medical procedures that were unnecessary in the first place, or they extend the period of stay in the facility. This enables them to bill the stay or procedures to Medicaid and Medicare. Unnecessary procedures can be dangerous for patients because they can complicate underlying medical conditions or cause unwanted side effects.
Kickback laws prosecute nursing homes that accept benefits while they are involved in prohibited referral relationships. An example would be entering contracts with pharmaceutical companies who, in turn, have below-cost agreements that allow them to supply prescription drugs to the facility’s patients. Another example is when a nursing home receives discounted or free ambulance transport while it keeps the savings that they should have paid out. In exchange for the cheaper rides, the facility gives out Medicaid and Medicare referrals to ambulance companies who bill the healthcare programs for higher rates.
We Will Work Together to Protect Your Loved One
Ben Crump Law, PLLC knows the decision to place loved ones in a nursing home does not come easy, and it can be distressing to see them suffer or lose their dignity under the supervision of others. Healthcare abuse and fraud in nursing homes can emotionally and financially impact residents. When the facility deprives them of their funds, they may not be able to afford to pay the nursing home and necessary medical services. Injury can also result from unnecessary procedures or inadequate care. They may feel fear, anger, anxiety, all of which can lead to depression and poor health.
If you think a nursing home is not providing your loved ones with the treatment and care they deserve, do not hesitate to talk to us today at (800) 959-1444, or get in touch with us online. Please take advantage of our free consultations so you can learn more about your legal rights and available options.