Nursing Homes Bill for More Therapy Than Patients Need, U.S. Says

This is so multifactorial. I really believe that Health and Human Services and Medicare needs to work on the front lines to see the issues. I work in an acute care hospital. My patients have had horrible experiences in rehab in nursing homes and I hear the stories. Some have told me that they want to leave and go home and are told they cannot because their Medicare claim will be denied and they will have to foot the entire bill. Some have told me they have been "held hostage" for the entire qualifying stay because the nursing home wanted full payment from their "good insurance". Some tell me how little therapy they actually get ... and how ineffective it is and based on RUG levels and "minutes" rather than what their true goals are. I am quite hesitant to refer a "high level" patient to a nursing home in fear that the ONE hour of therapy that they might receive five days per week might not offset the TWENTY THREE hours they spend sitting in a chair or a wheelchair. Believe me, therapists want to do "right" but I believe nursing homes threaten them if they don't maximize the potential minutes that might be available. I know therapists who have left nursing homes because their ethics are challenged in this manner including nursing home administrators asking them to leave. Others don't have good ethical prowess and just continue with the status quo to earn a paycheck. Wrong, wrong. I will continue this post in the next post....

I am a former Occupational Therapist and can evaluate the quality of care. My father was recently at a facility that focussed on the billing. It became obvious that he was going downhill mentally and physically due to the poor care. This included having him in diapers instead of getting him up to the commode and having him take meals reclined in bed even though he was aspirating. Physical Therapy and Occupational Therapy were provided by the OT in a poorly equipped overcrowded room. Long "rest breaks" added to the billable hours and allowed the therapist to treat other patients that were being billed for the same time slot. The Respiratory Therapist that came in did not even know what they were treating him for. In order to get the facility to cooperate with a transfer we had to look the other way as the facility lied about his intake and discharge levels so they could get paid because goals were met.
To me the bottom line is that healthcare is a for profit industry that will work around the good intents of any rule change. The best hope I see is in social media; a trip advisor of facilities that accept Medicare. Medicare should have a questionnaire that checks specific quality measures. This would also teach families what the measures of quality are and provide greater accountability.

Health care fraud is very difficult to prosecute because medical records are easy to fake, it requires medical expertise on the part of prosecutors that can be challenged by defendants' expert witnesses, it uses up an inordinate amount of prosecutors' time and, failing all else, the defendant can claim that "mistakes" were made because of an overly complex system. In this environment, swift and sure justice requires a non-judicial system that depends on a lower level of evidence and results in the fraudulent operators being fined and put out of business.

The nursing home business is and always has been a despicable business. Almost all of the nursing home owners are scam artists that provide very poor care and maximize reimbursements. But because they are enmeshed in the political system of each state, they continue. Very disturbing. In no other country (other than the US) do our type of nursing homes exist.

I find it interesting that the article mentions the 1 billion dollar "fraud" of therapy in skilled nursing and nothing more. No mention of the $585 billion total medicare spending for that period. No mention of $271 billion for prescription drugs. But let's go get the therapists making people get up and move to increase blood flow, function, general well being, or maybe teach strategy to avoid loss of balance perhaps caused by the same medications extending their lives. I don't deny that some of this is unnecessary, but let's also discuss unnecessary medications, imaging, surgery, redundancies, and waste. The answers are there, the laws are already in place. They need to be enforced fairly and not according to who has the most expensive lobby.

Well, having worked as a physiotherapist for 25 plus yrs, I can assure you that this story has more than one side. Many patients are hospitalized multiple times simply because their family members can no longer care for them at home and manage to persuade their physician to put their loved ones in an acute hospital to see if they can (at least) qualify them for rehab placement. Note, that the Medicare rules allows 60 days of Rehab each year for a qualifying illness. So, in the view of many clinical and rehab personal who serve on the frontlines of helping returning our elderly, sick and injured patients to at least a minimal level of functioning, the question of the needless hospitalization or rehab placement of our elderly and ill begins with questions not easily answered by simple greed-It may in fact involve hard choices our nation may not be ready to tackle.

This is far from surprising. Not long ago, 60 Minutes revealed that hospital emergency room doctors were instructed to target patients, 65+, and admit at least 20% of them. For what reason? In order to bill medicare, of course. Republicans would like to dismantle this program, along with Social Security, but failing that they will allow such abuse of the elderly.

It's not the amount of therapy but the quality of the therapy. You can't jerk a 90-year-old out of bed at 7 am or wake her up at 7 pm for meaningful physical, occupational, or speech therapy as was often done to my mother. Also, when my mother in her disorientation "refused," Medicare still was billed. "Meaningful" physical and occupational therapy happened most often at the same time. For example: the physical therapist had my mother stand while the occupational therapist had her play catch with a big ball. Or, my mother was walked with her walker with one therapist next to her while the other therapist followed with a wheelchair in case my mother got tired and needed to sit down. Each therapist billed for her separate "hour" of therapy.

And where are the good Doctors who make the decision to prescribe torture to the dying instead of grief counseling with the family? And the family? Are they near? And in agreement, understanding that we all must die. And the patient who insists that they don't want to die in a facility but grasp at every option offered until they succumb to the torture? And the Congress who hasn't the will to do more than complain about bad government but never seems to create good government with a single payer system that would get the whole problem farther from the private sector profit motive? And the public who doesn't want to be involved in the messiness of government but flocks to a reality show freak put forth by the press?

Well, for me the solution is Bernie Sanders who supports single payer health care for all which would be much cheaper in the long run. But I'm also working hard for him because he is telling us that realistically we can't have a responsive, good governance without a revolution of caring and being involved.

Whether it's nursing homes or medicaid providers, the only way to keep both the government and our most needy citizens from being ripped off is through more rigorous investigation and auditing and prosecution where warranted.

These are crimes of opportunity. The owners of these companies know that they are unlikely to get audited and so they steal from the public, often with impunity. Congress needs to invest more in watchdog and auditing efforts. These costs would easily be made up by the money they save. Maybe the drug enforcement model should be used. The prosecutors offices would be able to keep the money recovered as long as it was spent on investigating other white collar crimes.

I was present when a therapist came to the bedside of a friend who was 102, had two broken femurs, leukemia and had only two weeks or so to live. You could have knocked me over with a feather when she told him that they were ready to get him back into physical (occupational?) therapy.

Medicare provides the framework for these places to bilk the government (taxpayers), just like the 30M in ambulance fees Medicare has no accounting for. Blame government, not these nursing homes.

I am an occupational therapist and have practiced in several area skilled nursing facilities. The majority of rehab patients were placed in the ultra high category. At least 50% of these patients were not appropriate for this level of care. Rehab potential was often rated as "good" even though their medical history indicated a poor to fair potential. The majority of patients were seen for the maximum 100 days of therapy paid by Medicare. Some of these patient ended up being transferred to long term care facilities. The biggest push in these facilities is for getting those daily therapy minutes in to meet the ultra high category. Now, many skilled nursing home and rehab companies have developed documentation software that assures the correct wording for writing goals and documenting progress. This lessens the chance of claims being denied. None of this suggests that patients appropriate for therapy aren't getting the essential rehab they need. However, this does suggest that shilled nursing home facilities which are for profit businesses are incentivized to keep as many patient in therapy as possible.

While this happened some years ago, I shall never forget the pitiful cries of an old friend living her last days in a nursing home who clearly did not want to be forced to move and in fact died a few days later, the only conceivable reason for continuing being that physical therapy had been prescribed and administered no matter what and appropriately billed. This despite my own pleas and those of my husband who actively tried to intervene. It was only after she had been forced to take a few staggering steps that the staff was satisfied.

Nursing homes are full of patients that could be treated at home. Homeless with Insurance Medicaid, mental health patients.
The Nursing home belong to a chain of NH of a group of business men.
The services are given according to what the insurance will pay and not what the person needs.
The doctors write notes and billing according again with what the Insurance will pay and not according with patients needs. Also the doctors belong to groups were the only interest is making money
The function of the Medical Director is to diminish expenses and most of the times belongs to the same group of physicians
In general the punishment will be to "return" some money.
Is time one for socialize medicine and to punish with jail.

What a surprise. Billing for more treatment than necessary. Take a look at some of the "injury clinics" around that leach off of insurance claims.

Duh. My aunt, in a nursing home in Greenwich, Connecticut, noticed this and thought it was a scandal. My father, in the final stages of congestive heart failure, was given physical therapy that diminished his already weakened state. It actually felt like something that might be a violation of the Geneva Convention.

Shame, shame, shame on nursing home owners, these epically strange profiteers, and lawmakers for not putting an end to the practice.

"Greg Crist, a spokesman for the American Health Care Association, said that while Medicare may pay nursing homes more than their costs, Medicaid, the program for low-income people, generally pays them much less than their costs. 'And on any day,” Mr. Crist said, 'two-thirds of our residents are on Medicaid.'"

And this is exactly why nursing homes are overbilling Medicare as much as possible. They know the gravy train is going to stop at some point, and the patient will have gone through "spend down" and will be eligible for Medicaid. So they bill and bill and bill Medicare for as long as possible.

And it continues on up the chain. When we were looking at nursing homes for my mother, one administrator frankly told us that the reason patients paid so much (out-of-pocket) for the first 6 months or so was that the nursing home needed to maximize revenue from that patient while they could; once Medicaid kicked in, the nursing home would receive significantly less money per day for that patient.

As an aside, I am hoping the articles does not conflate nursing homes with skilled nursing facilities (SNFs), which are often located within or next to nursing homes. As I read the article, it was sometimes hard to tell if it was a nursing home (i.e., a long-term residential facility) or a SNF (i.e., a short-term subacute rehab facility) that was being discussed.

Why do these findings surprise ANYONE?

The bureaucracy and lack of regulatory oversight are ripe for corruption and theft. The system is in need of a complete overhaul, with local oversight by something akin to an institutional review board, which is always required for clinical research. And it should be an INDEPENDENT review board, excluding owners and management of the facility.

I dread the time that _I_ am shuttled off to one of these homes of horror.

The mention of hospice care concurrent with rehab in nursing homes deserves elaboration. Double dipping? No, but close.

This is how things work. A Medicare patient hospitalized on inpatient status (an important distinction, observation status doesn't qualify for this purpose) for a minimum of three consecutive billable hospital days ("billable" days are not to be confused with "days" as you count them, another story for another day) may receive rehab and room and board at a skilled nursing facility (SNF) for up to 100 days on Medicare's dime. the first 20 days at 100%; the remaining 80 the patient is responsible for a daily co-pay of about $150.

Medicare will pay for both hospice and rehab if (BIG "if") the disease diagnosis for hospice services is unrelated to the disease or injury that led to the hospitalization for which rehab is now desired. All too often, even if this distinction can be made, the patient is in no condition to participate in and benefit from rehab. If there is no way to claim the two problems are unrelated, families opt 99% of the time to revoke hospice care and go to the SNF for "rehab." All because the first 20 days are "Free!"

It is rare for a patient on hospice care who enters a SNF for rehab to still be alive on day 21, rarer still for that person to survive the full 100 day allowance. Not much benefit from rehab when the patient leaves on a funeral home gurney.

Medicare would save money by placing full-time in-house rehab monitors in SNFs.

I understand that the nursing homes detailed and investigated by the DHHS have done wrong. That's without a doubt true. But, what I do not understand, is why the DHHS & OMIG lets the violations happen instead of doing something proactive. Where were the audits throughout the year? How thorough were the audits? Penalizing the nursing homes after the fact, after they have done wrong and billed for services that were not delivered or necessary, only ends up hurting the people who work and live there. Their poor quality of life just ends up diminishing further as the organization scrambles to remove those who have acted dishonestly. Then, of course, the direct care staff get their few benefits and perks taken away, followed be less care towards the clients.

Remember Rabbi Bernard Bergman and the Nursing Home Scandal presided over by then Assemblyman Andrew Stein, aided in his campaign by a catastrophe of press manipulated, some said, by his father, Jerry Finkelstein, publisher of the New York Law Journal, and arbiter of which legal cases 'got ink?'

At its core - nursing homes are about the tension that exists between getting old and being able to take care of oneself.

Jerry Finkelstein was a multimillionaire who lived to the ripe old age of 96 and died in his home. But, as the Brooke Astor saga revealed even such scenarios can be fraught, as relatives, emotions, banks and medical opinions can weigh in, each with a stake in their unique perspective.

For many if not most Americans, 'assisted care' and 'assisted living' facilities are the 'last stop gas station on the highway.' They are the dry rehearsal for the hearse and obituary the media keeps on file for the inevitable day. They are also a potentially lucrative model for amassing real estate and generating profits and can be as sought after as prestigious boarding schools by harried, wealthy, middle aged parents at their wits end as to how to care for their own parents. As the grandchild answers when asked, what happens when you grow old? "You go to Boca or Palm Beach.''

Bernard Bergman wound up getting convicted and sentenced to four months, which prosecutor Charles Hines succeeded in getting doubled. The Bergman family is still bitter. Some issues never die.

Document, document, document. I have a great deal of documentation of abuses by a local nursing facility. I even questioned why the 'therapy' was every other day for a month and a half and then no therapy took place until the next year. ...Of course it was to bill medicare! One director told me that she did not know why the therapy was taking place other than the therapist walked around and "just grabbed people." Abuses by some nursing facilities is not new; Authorities have just decided to address the problems.

"The acting administrator of the Centers for Medicare and Medicaid Services, Andrew M. Slavitt, did not dispute the findings. He said the current payment system created an incentive for nursing homes to “provide as much therapy to a resident as that resident can tolerate.”"

No surprises here. Fraud and abuse have existed since time began, and will continue. And for those who scream "privatization", note these homes are already private. Privatizing the entire system by outsourcing nursing home care would be an open invitation for rapacious firms to jump in line for government benefits.

Of all the proposals listed here, I think the "fee per patient" makes the most sense. Sure, the fee may be high for patients not needing much care, but let's face it, most do or they wouldn't be there. Think how much in savings could be generated if one didn't have to track every single "intervention" and therapy a patient receives. One annual payment per patient. Simple, and clean with no opportunity to cheat.

On Medicaid coverage, the reason most elder care is delivered through that program is the 'spend down' policy and the high cost of nursing home care. Families the know the rules and plan ahead can get the old folks into Mediciad covered nursing home stays faster than the average family with low means whose loved one suddenly suffers a stroke.

But the name of the game is to move nursing home patients from Medicare to Medicaid as quickly as possible.

In my experience with nursing homes in NYC, there is no question that they frequently claim for care they do not provide, and that they often do NOT provide care that is truly needed. This has been going on for ages, and it's not going to change unless/until the government actually puts teeth into the penalties for fraudulent billing.

The people who own & operate for-profit nursing homes should be subject to thorough & deep investigation by the government - and there need to be anti-bribery controls in place, as well.

Sadly, it seems that no matter what protocols are put in place to manage costs, health care providers will simply adjust their strategies to maximize continue maximizing profit with no regard to the needs of the patient. The response to the current system is to pay health care providers for "outcomes" the prospect of which I find frightening, because if I disagree with a doctor's prescribed treatment plan or medication, the doctor will have an incentive to drop me as a patient because my disagreement may cost them a reimbursement. The whole health care system in the US has become perverse.

Healthcare of all types has been reduced to an industry of selecting billing codes that are submitted to Medicare, Medicaid, private insurers and individuals. The entire industry is based on billing not healing. An elderly friend told me that at a recent doctor visit, he (Medicare) was billed $20 for sitting in the waiting room area. Use of the waiting room is now a separate billable service.

This article examines billing for unnecessary services. But what about all the services they billed for that were never done? Who is going to know? No one is watching. These are for profit centers. They will bill for whatever they think they can get away with.

Fee for service is the problem. This type of healthcare cannot be regulated by traditional market competition because the buyer is unaware, unable to select, and 100% captive. Nursing homes as well as all of healthcare are bankrupting the nation because of these abuses.

The push for profit negates honesty in billing at all levels in all activities. Socialization of the industry is the only way to stop these abuses. Profiting on sickness and dying is a never ending gravy train of money.

33 years ago I worked at a nursing home while attending nursing school. Many of the aides who made $5.00 an hour were heroic in their care for the sadly infirm residents. However, on "dentist day", the wheelchairs were lined up out the hall and the dentist came in and peeked into everyone's mouth as they were wheeled up the line, into the room, then out the door on the side. My understanding after asking the charge nurse was that each person in the line got billed for a dental exam.

Names, we need names. Not this endless cloud of labels.

Well let's see, a couple of years ago I saw prospectuses from Goldman Sachs for funds to acquire long-term care facilities and now we hear of over billing? And we are surprised?

I have had cause to experience this but It may be warranted to get the patient to their best level of physical fitness for the assessment to determine there long term care status.

Across the US healthcare system there is much profit based, wasteful and unnecessary treatment. This adds complexity to a patients care program and undermines meaningful care efforts. It also increases the difficulty for individual patients/families to assess valid diagnosis info from noise, also undermining the quality of life and quality of care for each patient.

It is clear we need to move to more coordinated care with specialists used in response, not in search of, diagnosis and findings. Care plans need to be focused on the patient, not cost or profit. Accountability and care result based payments need to be instituted across the board to create a foundation for improvement.

Patient should drive change, ask for an itemized bill and write to the providing institution detailing both appropriate and unnecessary care feedback.

Discharge survey's used as part of a rating for providers would also improve accountability.

The soul-less capitalists who own the U.S. Congress, and who run the health care system for profit, line their pockets with taxpayer money?

I'm shocked!

As a physician in practice for over 30 years, I can tell you this practice is rampant. I have complained repeatedly to hospital social workers about discharging patients to "skilled care" when they are clearly dying and completely incapable of participating in any level of "therapy". Unadulterated fraud.
The nursing home will then insist on a "swallow evaluation" and force the family to have a feeding tube placed which is actaully contraindicated in these patients as it causes more problems and does not help patients get stronger, gain weight or heal skin breakdown.
Medicare needs an expanded hospice option to house patients who need custodial care at end of life. It would be better for patients and their families and cost less than this sham care they are subsidizing.

This happens at all levels of health care. I've discovered things on my bill at the doctor's office that weren't done. The hospital that now owns the practice has things structured to make it as difficult as possible to challenge charges.

For any challenges, the patient must file a complaint. The complaint is reviewed by a committee that the patient is not allowed to talk to in a meeting that the patient is not allowed to attend. The patient is not allowed to speak with the person who rendered the service and is not told if the committee spoke with them. The verdict is given by phone to the patient.

The most surprising aspect of the whole process is how shocked they seem when the patient finally gets their lawyer involved.

medicare fraud has been going on a long time. Having been involved with the program and having seen its excesses, I have written and called them on it many times to no avail. Unless the political will is greater than it is today, or the public really becomes outraged by the fraud will continue. The money is there for them to take.

Some of these health care/nursing home operators need to be indicted, tried and imprisoned instead of getting the usual slap on the wrist and proceeding to treat their actions as a cost of doing business while they enrich themselves at public expense. They belong in orange jump suits rather than living in palaces and getting themselves elected governor in places like Florida.

Hospitals, too. My aunt, sitting by her husband's bedside, watching him sleep, saw a man peek into the room, go to the chart, note something, and then leave. Turns out that he was a psychiatrist, and he billed for a session. Plus the fact, my uncle never needed psychiatry -- he was the sunniest, best-balanced human being that ever lived.

My mother, ever vigilant, and very good with numbers, scrutinized her bills the few times she had hospital stays. She would find charges for procedures not performed and notify Medicare. Payments would be denied. And that was that.

My mother passed away one year ago after a 6 month "stay" in a nursing home, not her choice, but the choice of her "health proxy", a sibling with no health care knowledge who refused my pleas to change plans. She was initially placed in a nursing home from the ER for a few weeks physical therapy for a dislocated shoulder, following a fall, under the guise that a nursing home would be safer. This was hardly life threatening. In no time at all she was apparently "diagnosed" with very acute problems even though she was completely ambulatory, and could have managed at home with an aide, at a much lower cost to society. The nursing home was not safer, she fell walking on highly polished floors, and she was poorly supervised by overworked staff, as an "easy" patient. Her emotional state was poor, heartbreaking. She has significant hearing loss, but was wrongly given a diagnosis of dementia by a GP because she couldn't hear what he asked her. The owners of the Home, a network of financiers that own many other Nursing homes throughout the county, are able to maximize profit at the expense of the most vulnerable, and it is completely legal, and completely OK. I did call my local elected officials about this, to investigate and trust me, and they could care less. So what is the solution to this elder abuse?

I have cause to call various nursing homes and discuss their costs with the director and/or billing department. The range for a month stay in a nursing home has been reported as between about $3,000 and up to $19,000. Oversight on the cost of services is desperately needed.