Florida Nursing Home Quality of Care Violations

Quality of care is a measure of the care that patients receive at nursing homes. Residents of these homes have a right to expect safety, hygienic environments, and the appropriate treatment. When nursing homes take money from the government, it’s not only the patient’s expectations that matter.

When any nursing home bills Medicaid of Medicare (for skilled nursing care), they are declaring that their services are up-to-standard. That means low-quality services don’t merely harm the patient—they also represent fraud against the government. That fraud can be prosecuted severely using the False Claims Act.

Blowing the Whistle on Healthcare Billing Fraud

Healthcare billing fraud happens when healthcare providers—including doctors, hospitals, and nursing homes—knowingly file incorrect claims. 

The false claims may be submitted to patients or insurance companies. In most cases, however, the target is public programs such as Medicare and Medicaid. These programs don’t have the resources to audit every claim, so they rely on whistleblowers who work for these facilities.

Telemedicine Fraud

Telemedicine is the use of real time face to face telecommunication by a doctor or clinician to treat a patient at a distant site.  The live patient communication software platform is designed and provided by companies that specialize in providing services to the medical field.

For telemedicine to occur three factors must be present:

  • Different locations of provider and patient at time of treatment
  • Treatments and services completed must be clinical in nature 
  • Asynchronous (live two way) communication

Currently, for telemedicine to be lawful the physician must be at a “hub-site” (designated medical care location) and the patient at an “spoke-site” (distant origination location).  

When medical coverage is available to patients at a distant location, doctors or licensed medical practitioners can treat them clinically.  At-a-distance clinical medicine is also part of the telemedicine definition and is what differentiates it from telehealth.

Hospice Fraud

Hospice care is defined by the Federal Code of Regulations as a “comprehensive set of services … to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members.” Such end of life care is often provided using taxpayer dollars through federally funded programs such as Medicaid and Medicare. Hospice care through Medicare or Medicaid is available for terminally ill patients with a life expectancy of six months or less if their illness were to run its natural course.   In order to receive hospice care a patient must be certified terminally ill by a physician.  Hospice care services can be provided in the home or at a nursing home facility and are often accompanied by palliative treatment focused on pain and stress relief. Once a patient elects hospice care they can no longer pursue curative treatments, unless they are under 21 years of age.

What constitutes hospice fraud?

The U.S. Department of Health and Human Services, Office of Inspector General recently audited Medicaid hospice providers and identified a number of transgressions ranging from inappropriate billing resulting in over-payments, poor patient care, submission of claims that did not meet care standards, medical records that did indicate terminal illnesses and providing misinformation to patients and caregivers.  When done knowingly these actions would constitute fraud against the federal government and give citizens the right to seek justice on its behalf.

Hospital Fraud

Hospital fraud is a broad term that refers to any action a hospital may take to improperly bill the Medicare and Medicaid programs. 

This type of fraud is a serious problem. A large percentage of the billions of dollars that are distributed by public health programs every year are paid directly to hospitals for the services they provide to patients and outside treatment centers.

Fraud involving hospitals is not easy to detect. Most hospitals around the nation process thousands of transactions every day as tests are performed, drugs are provided and treatments are administered. Fraud can slip through the cracks at any large facility, even without the administrators being aware of it.

The important work that hospitals do further complicates the detection of fraud. When auditors interfere with the daily operations of hospitals, it can endanger patients. In order to avoid threats to the patients, regulators rely heavily on whistleblowers within the hospital to provide evidence that proves fraud. 

Whistleblowers are highly incentivized to reveal fraud because, under the False Claims Act, they are entitled to receive a portion of all funds that are recovered.

Medicare Fraud

Medicare fraud is a broad term that covers any action that results in the defrauding of the Medicare public health insurance program. As one of the largest insurance programs in the US, it makes billions of dollars in disbursements every year to providers that include doctors, hospitals, pharmacies, hospices, and drug manufacturers.

The amount of money and transactions involved can make fraud tempting and difficult to detect. However, the government has many tools for detecting and reclaiming money lost to fraud—even years after the fraud was committed.

One of the ways the fraud is detected is through the use of the False Claims Act and the incentives that law offers to whistleblowers who are directly employed by the providers who receive Medicare funds.