How to report Skilled Nursing Facility fraud (SNF fraud) and receive a whistleblower reward

This article addresses how to report Skilled Nursing Facility fraud (SNF fraud) and get a reward for receive a reward for reporting SNF fraud, which amounts to Medicare fraud.

Reporting Skilled Nursing Facility services (SNF fraud)

There are a few common types of Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) that can result in a sizable whistleblower reward.

The first Skilled Nursing Facility fraud (SNF fraud) occurs when a Skilled Nursing Facility bills Medicare for stays that do not qualify for Medicare reimbursement, such as not having a qualifying stay in a hospital prior to being transferred to the SNF. A second form of Skilled Nursing Facility fraud (SNF fraud) occurs when a Skilled Nursing Facility bills Medicare for more than 150 days for one spell of illness. A third form of Skilled Nursing Facility fraud (SNF fraud) occurs when a Skilled Nursing Facility upcodes its RUG rates (RUG upcoding SNF fraud).

Examples of non-qualifying Skilled Nursing Facility fraud (SNF fraud)

Medicare covers medically necessary admission to a skilled nursing facility (SNF), but only when other eligibility requirements are met. Specifically, in order for a Skilled Nursing Facility to bill Medicare, the Medicare recipient must be transferred to a skilled nursing facility (SNF) from a hospital in which he was “an inpatient for not less than 3 consecutive days before his discharge from the hospital.” In other words, the Medicare patient must have spent at least 3 consecutive days in a hospital to be eligible for skilled nursing facility (SNF) reimbursement from Medicare. It is skilled nursing facility fraud (SNF fraud) if the SNF lies about the number of days in which the Medicare patient was at a hospital, such as 2 days. When determining the 3 days, the SNF must exclude the day the patient was admitted to the hospital and the day they were discharged. In addition, time spent in “observation status” does not count. Similarly, if the patient is not transferred to the SNF within 30 days of treatment from a hospital, the Skilled Nursing Facility may not bill Medicare or Medicaid.

It is also Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) if the treatment at a SNF is not medically necessary. Skilled Nursing Facility care is healthcare that “requires the involvement of skilled nursing or rehabilitative staff in order to be given safely and effectively.” It is Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) for a SNF to bill Medicare if the patient only needs “custodial” care, but doesn’t also require “skilled” care. Medicare defines “custodial care” as non-medical care that provides assistance with activities of daily living, such as bathing, dressing, or eating. To bill Medicare, the SNF patient must also need the skilled care, such as intravenous injections, physical therapy, catheters, wound care, or ostomy care. It is Medicare fraud for a Skilled Nursing Facility to bill Medicare for custodial care that does not also require skilled care.

Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) can also occur if the Medicare patient got better, but the SNF kept providing skilled services or claimed to provide treatment or skilled services that were not medically necessary. Similarly, it amounts to SNF Medicare fraud to begin treating the patient for an alleged new illness or new form of treatment that was not the condition or injury that was being treated by the hospital.

Examples of SNF Fraud by billing more than 150 days for one spell of illness

Medicare only covers Skilled Nursing Facility care on a short-term basis, and only such as to help improve your condition, maintain your current condition, or prevent it from getting worse. Generally, Medicare will only pay for 150 days for a single spell of illness. It is Medicare fraud for a Skilled Nursing Facility to break one spell of illness into two spells to bill for more than 150 days. In fact, the entire time spent in the hospital and SNF facilities get combined towards the 150 days for a single spell of illness.

Examples of Upcoding RUG Skilled Nursing Facility fraud (upcoding SNF fraud)

Another example of Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) is RUG upcoding fraud. Medicare requires Skilled Nursing Facilities to properly code patients using the RUG III Grouper. Each category has different relative weight factors that determine the per diem Medicare pays for each SNF patient. It is Medicare fraud to upcode or bill to a higher code or level of service. It is also Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) to use incorrect codes or place a patient in the wrong group to get a higher-paying RUG category.

Tips for how to receive a reward for reporting Skilled Nursing Facility Medicare fraud (SNF Medicare fraud)

Many ask how to report Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) and receive a reward. The government pays whistleblowers a reward for reporting SNF fraud. But you must report Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) in a particular way to receive a whistleblower reward.

First, you cannot receive a reward by calling a hotline or even sending an email to the government to report SNF fraud. Instead, you must hire an attorney (typically on a contingency basis) to file a False Claims Act qui tam action against the Skilled Nursing Facility that is cheating or defrauding Medicare.

Second, you must identify specific evidence and examples of Skilled Nursing Facility Medicare fraud (SNF Medicare fraud). Your attorney will help you evaluate your alleged SNF fraud and determine if you have the right case to file for a reward.

How to determine the amount of a whistleblower reward for reporting Skilled Nursing Facility Medicare fraud (SNF Medicare fraud)

The amount of the whistleblower reward for reporting Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) is set by the whistleblower reward statute at between 15-25% of the amount of money the SNF repays for defrauding Medicare or Medicaid. For instance, if a Skilled Nursing Facility over charges Medicare and agrees to repay $10 million, the reward is between $1.5 million and $2.5 million, assuming you are otherwise eligible for a whistleblower reward and properly report the SNF fraud.

How to decide whether to report the whistleblower reward statute pays the whistleblower a reward of between 15-25% of the settlement amount

Mr. Hesch is available to evaluate your allegations of Skilled Nursing Facility Medicare fraud (SNF Medicare fraud). You can find out in confidence whether Mr. Hesch thinks you have the type of Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) case where you may be eligible for a significant monetary reward. How to report Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) and seek a whistleblower reward begins by filling out the questionnaire on this website. Mr. Hesch and the team of attorneys that work with him on Skilled Nursing Facility Medicare fraud (SNF Medicare fraud) cases will review your information and let you know if they can represent you in reporting Skilled Nursing Facility Medicare fraud (SNF Medicare fraud). It is important to carefully select your attorney because the government turns away 75% of reward applications.

See the link at the bottom of the page below “Do I have a case” to have Mr. Hesch review your potential whistleblower reward case for Skilled Nursing Facility Medicare fraud (SNF Medicare fraud).

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