Skilled nursing facility to pay $819,640 to resolve fraudulent billing claims
PHILADELPHIA » A Lower Merion Township skilled nursing facility must pay more than $800,000 to resolve False Claims Act liability arising from billing of rehabilitation therapy, according to federal prosecutors.
U.S. Attorney Jacqueline C. Romero announced on Friday that Old Man’s Home of Philadelphia, doing business as Saunders House in the Wynnewood section of Lower Merion, will pay $819,640 to settle claims that the skilled nursing facility provided medically unnecessary rehabilitation therapy to residents to maximize revenue, and without prioritizing clinical needs.
“Focusing on profits over the needs of individual patients violates the public trust and creates a potential for harm of some of the most vulnerable among us,” Romero said in a news release. “It also shifts taxpayers’ funds away from the vital services of law-abiding therapy providers.”
The settlement resolves allegations in a whistleblower complaint filed in federal court in the Eastern District of Pennsylvania under provisions of the False Claims Act. Those provisions allow private citizens to bring civil actions on behalf of the United States and share in any recovery.
“We thank the whistleblower for helping to make the government aware of these allegations. We also thank Saunders House for fully cooperating with the government’s investigation — that cooperation was taken into account when determining an appropriate resolution of these allegations,” Romero added.
The whistleblower, a physical therapist assistant who provided physical therapy services at Saunders House through his employment with a contracted therapy provider, generally alleged that Saunders House overbilled federal healthcare programs such as Medicare for therapy services provided, federal prosecutors said.
He also alleged that Saunders House billed for services not provided, billed for unreasonable, unnecessary, and sometimes harmful therapy, and allowed the therapy provider to manipulate clinical services to maximize billing, according to federal prosecutors.
During the relevant time period, Medicare Part A paid for services rendered to a beneficiary in a skilled nursing facility at a daily rate based, in part, on a Resource Utilization Group (RUG) to which the beneficiary is assigned. Each distinct RUG was intended to reflect the anticipated costs associated with providing nursing and rehabilitation services to beneficiaries with similar characteristics or resource needs, officials explained.
The highest reimbursement level was Ultra High or RU. The resolution is based on claims that Saunders House caused the submission of false claims for Ultra High RUG therapy levels despite evidence that the RU level of therapy was not reasonable or necessary for the respective patients.
“Protecting the integrity of our Medicare program is of the utmost importance,” said Special Agent in Charge Maureen R. Dixon of the U.S. Department of Health and Human Services, Office of the Inspector General. “Patients need to depend on the decisions made by their health care providers and know those decisions are made to improve their conditions and not to increase providers’ individual profits.”
The settled civil claims are allegations only. There has been no determination of civil liability, officials said.
Assistant U.S. Attorneys Landon Y. Jones III and Elizabeth L. Coyne handled the case with assistance from auditor Dawn Wiggins, and worked with Albert Mayer, trial attorney, of the civil fraud section of the Department of Justice.
The case was investigated by the U.S. Department of Health and Human Services Office of the Inspector General.
Officials said the Department of Health and Human Services will continue to work with the U.S. Attorney’s Office to investigate allegations of fraudulent actions.