A weapon against nursing home fraud and abuse.Using the federal Civil False Claims Act, plaintiff attorneys can fight fraud and ensure that nursing home residents who receive federal benefits get the care they need.
America is aging. As the baby boom generation moves from middle age to retirement age, tens of millions of Americans will be entitled to Medicare benefits. A significant percentage of these recipients will rely on Medicare as the primary means of obtaining health care.
Currently, about 1.6 million people, including the elderly and people with disabilities, are cared for in the nearly 17,000 nursing homes operating in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . As the percentage of our population over age 65 increases, the percentage of elderly people entering nursing homes will likewise increase.
Nursing home care is one of the fastest growing areas of Medicare and Medicaid Medicare and Medicaid
U.S. government programs in effect since 1966. Medicare covers most people 65 or older and those with long-term disabilities. Part A, a hospital insurance plan, also pays for home health visits and hospice care. spending.(1) Unfortunately, a significant portion of this money is going into the pockets of unscrupulous health care providers.
The General Accounting Office estimates that about 10 percent of the federal budget is lost to fraud and abuse in federal health care reimbursement programs.(2) The Department of Health and Human Services' Office of Inspector General Noun 1. Office of Inspector General - the investigative arm of the Federal Trade Commission
independent agency - an agency of the United States government that is created by an act of Congress and is independent of the executive departments has identified nursing homes and home health care as target areas of fraudulent schemes.
The federal Civil False Claims Act,(3) with its qui tam QUI TAM, remedies. Who as well. When a statute imposes a penalty, for the doing or not doing an act, and gives that penalty in part to whosoever will sue for the same, and the other part to the commonwealth, or some charitable, literary, or other institution, and makes it recoverable by provision, has become one of the primary means the government has for fighting fraud in Medicare, Medicaid, and CHAMPUS CHAMPUS Civilian Health & Medical Program for Uniformed Services A health care plan for military dependents and retirees operated by the DoD Types of service HMO, PPO, and fee-for-service, through a single health plan known as TriCare or TRI-CARE programs. It has been successfully used to stop fraud and ensure that nursing home patients who receive federal benefits also receive the minimum standard of care required by the Nursing Home Reform Act.(4)
Plaintiff attorneys accustomed to handling negligent care or other tort actions for nursing home residents may not know about the legal tools available to fight the underlying problem of fraud in federal reimbursement programs. By using one of the most effective tools, the False Claims Act, attorneys can fight fraud and, in turn, ensure that nursing home residents who receive federal benefits also get the care they need.(5)
Sometimes referred to as the "Lincoln Law," the False Claims Act was passed at the urging of President Abraham Lincoln in 1863 to combat the fraud being perpetrated on the Union by profiteers selling shoddy, defective, or nonexistent non·ex·is·tence
1. The condition of not existing.
2. Something that does not exist.
non goods. The act included monetary incentives for private individuals to combat the fraud.
This bounty concept was derived from English common law, which provided compensation for a person "who brings the action for the king, as well as for himself." The term "qui tam" is an abbreviation abbreviation, in writing, arbitrary shortening of a word, usually by cutting off letters from the end, as in U.S. and Gen. (General). Contraction serves the same purpose but is understood strictly to be the shortening of a word by cutting out letters in the middle, of the Latin translation of that phrase--qui tam pro domino rege quam pro sic ipso in hoc parte sequitur.(6)
The False Claims Act qui tam provisions were amended by Congress in 1943. The provision allowing the party bringing the lawsuit on behalf of the government to receive 50 percent of any recovery was eliminated. The amendments gave courts discretion to award as little as nothing, and no more than 25 percent of recoveries.
The amendments also included a jurisdictional bar to a qui tam action qui tam action (kwee tam) n. Latin for who as well, a lawsuit brought by a private citizen (popularly called a "whistle blower") against a person or company who is believed to have violated the law in the performance of a contract with the government or in violation "whenever it shall be made to appear that such suit was based upon evidence or information in the possession" of the U.S. government. Consequently, government employees who possessed information forming the basis of qui tam allegations or fraud could not bring suit.
During the first few decades after World War II, America witnessed the rise of the military-industrial complex mil·i·tar·y-in·dus·tri·al complex
The aggregate of a nation's armed forces and the industries that supply their equipment, materials, and armaments.
Noun 1. and the creation and expansion of federal entitlement programs. By the 1980s, fraud and abuse in these programs was believed to be widespread, and in 1986 Congress amended the False Claims Act and strengthened its qui tam provision.
As a consequence of the amendments, a defendant can be liable for three times the actual damages Noun 1. actual damages - (law) compensation for losses that can readily be proven to have occurred and for which the injured party has the right to be compensated
compensatory damages, general damages sustained by the government and be subject to a civil fine of between $5,000 and $10,000 for each false claim submitted. A successful qui tam plaintiff--the "relator The individual in whose name a legal action is brought by a state; the individual who relates the facts on which an action is based.
The relator is the individual upon whose complaint certain writs are issued. " in the act's parlance--is entitled to receive between 15 percent and 30 percent of the funds recovered by the government.
The 1986 amendments eliminated the provision that automatically barred qui tam actions Civil actions maintained by private persons on behalf of both themselves and the government to recover damages or to enforce penalties available under a statute prohibiting specified conduct. when the government already possessed the information given to it by a potential relator. They also eased the burden of proof by eliminating the need to prove specific intent to defraud To make a Misrepresentation of an existing material fact, knowing it to be false or making it recklessly without regard to whether it is true or false, intending for someone to rely on the misrepresentation and under circumstances in which such person does rely on it to his or the government. Instead, defendants may be found liable if a preponderance of the evidence preponderance of the evidence n. the greater weight of the evidence required in a civil (non-criminal) lawsuit for the trier of fact (jury or judge without a jury) to decide in favor of one side or the other. shows they acted in "deliberate ignorance" or "reckless disregard reckless disregard n. grossly negligent without concern for danger to others. Actually reckless disregard is redundant since reckless means there is a disregard for safety. (See: reckless) " of the truth.
Practice and procedure
Liability under the act is established by proving that a person or entity improperly obtained money from the federal government or was improperly relieved of paying money to the government.
Most cases involve one or more of the following violations: (1) knowingly presenting or causing to be presented to the federal government a false or fraudulent claim for payment;(7) (2) knowingly using or causing to be used a false record or statement to get a claim paid by the federal government;(8) (3) conspiring with others to get a false or fraudulent claim paid by the federal government;(9) and (4) knowingly using or causing to be used "a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property" to the federal government (a "reverse false claim").(10)
Since the act was amended, the number of qui tam actions filed and the amount of money recovered by the government have greatly increased. According to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the Department of Justice (DOJ (Department Of Justice) The legal arm of the U.S. government that represents the public interest of the United States. It is headed by the Attorney General. ), $2 billion was recovered between 1986 and the end of fiscal year (FY) 1998.(11) Most of the recoveries have been in cases in which the DOJ intervened.
Only $60 million has been recovered by relators in cases in which the justice department did not intervene. Of the more than 2,400 qui tam cases filed since October 1986, the DOJ has intervened in 359 and declined to intervene in 1,252. The rest are still under investigation. On average, the federal government has paid to relators, as their statutory share, 17 percent of recoveries.
The percentage of cases involving health care fraud has increased dramatically since 1986. In that year, a little more than 10 percent of new cases that were filed involved the Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS . By FY 1998, the number grew to 60 percent.
A relator brings suit on behalf of the U.S. government. The case must be filed under seal, and the relator must disclose to the government all evidence regarding the alleged fraudulent conduct. This information is also provided under seal.
After the complaint is served on the government, it has 60 days in which to intervene.(12) In practice, the government usually asks for multiple extensions of time to intervene. It is common for a year or more to pass before the government makes a decision.
If the government intervenes, the complaint is unsealed, and the Department of Justice takes over the case. The relator may continue to materially participate in the litigation An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute.
When a person begins a civil lawsuit, the person enters into a process called litigation. and is entitled to between 15 percent and 25 percent of any recovery. An example of material participation would be the relator's submission of written discovery materials or participation at depositions, hearings, and trial.
If the government declines to intervene, the complaint is unsealed and the relator may continue to prosecute the action on the government's behalf. If successful, the relator is entitled to keep between 25 percent and 30 percent of the money recovered. Whether the government intervenes or not, the defendant must pay a successful relator's reasonable expenses and attorney fees.(13)
Based on the statistics, a case is more likely to succeed if the government agrees to intervene. Therefore, plaintiff lawyers should screen potential cases with this fact in mind.
Relators differ significantly from traditional tort plaintiffs in that they do not seek recovery for an injury or loss they have suffered. Instead, they bring an action on behalf of another party, the United States, for its loss.
The relator's role is to provide detailed knowledge of fraudulent conduct not previously known to the government. As such, potential relators must be scrutinized to determine the extent of the knowledge they possess, how they will come across as witnesses, and what their motivations are for bringing a qui tam action. Claims by former government employees with poor work records, personal grudges against the defendant, and limited personal knowledge of the fraud will probably not get the government's attention.
In nursing home cases, potential relators include anyone with firsthand knowledge of fraudulent conduct or of the delivery of substandard substandard,
adj below an acceptable level of performance. care to residents. Good candidates include former managers, medical directors, nursing directors, treating physicians, or other health care providers who have direct knowledge of the facility's operations, including billing procedures and patient care.
Unfortunately, nursing home residents --who are at high risk of abuse--are often unable to serve as relators. Most residents are not in positions that would allow them to observe systemic fraud or abuse in a facility. Also, they often have physical or mental disabilities that can hamper their ability to serve as effective witnesses. Therefore, a solid negligence case based on the abuse of a resident is not necessarily a viable qui tam action.
Punishment and prevention
Over the last five years, the Years, The
the seven decades of Eleanor Pargiter’s life. [Br. Lit.: Benét, 1109]
See : Time federal government has increased efforts to crack down on fraud and abuse in nursing homes where a significant percentage of Medicare and Medicaid expenditures are made. These efforts have included issuing special fraud alerts, conducting multistate mul·ti·state
Of, relating to, or involving several states: a multistate environmental campaign. investigations, launching special initiatives, and filing False Claims Act lawsuits.
Fraud alerts. In 1995, the Health Care Finance Administration began an initiative to weed out fraud and abuse in nursing homes and skilled nursing facilities skilled nursing facility
n. Abbr. SNF
An establishment that houses chronically ill, usually elderly patients, and provides long-term nursing care, rehabilitation, and other services. . In August of that year, the Department of Health and Human Services' Office of the Inspector General Office of the Inspector General (or OIG) is a common sub-agency within cabinet-level agencies of the United States federal government and serves as auditing and investigative arm of the agency's programs focused on identifying waste, fraud and abuse. published a special alert concerning fraud and abuse in the provision of medical supplies to nursing facilities.(14)
Some of the illegal practices uncovered by the Office of the Inspector General included submitting Medicare claims for medical supplies and equipment that were not medically necessary medically necessary Managed care adjective Referring to a covered service or treatment that is absolutely necessary to protect and enhance the health status of a Pt, and could adversely affect the Pt's condition if omitted, in accordance with accepted or were not provided, billing twice for the same item, and paying or receiving kickbacks in exchange for Medicare and Medicaid referrals.
In June 1996, the Office of the Inspector General issued a special alert regarding fraud and abuse in the provision of services within nursing facilities.(15) Fraudulent practices identified in that alert included making claims for services not rendered or not provided as claimed and falsifying fal·si·fy
v. fal·si·fied, fal·si·fy·ing, fal·si·fies
1. To state untruthfully; misrepresent.
a. claims to circumvent coverage limitations on medical specialties Medical Specialties
See also anatomy; disease and illness; drugs; health; remedies; surgery.
the science of the description of glands. — adenographic, adj. .
Both alerts provide examples of the fraudulent conduct listed, as well as guidance on how to identify similar fraudulent practices within nursing homes. They are useful resources for practitioners who are investigating potential false claims act cases.
Multistate investigations. In May 1995, the Clinton administration Noun 1. Clinton administration - the executive under President Clinton
executive - persons who administer the law launched a program called Operation Restore Trust (ORT), which was designed to stop health care fraud and abuse in the Medicare and Medicaid programs. ORT began as a two-year pilot project in California, Florida, Illinois, New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , and Texas--the five states where more than one-third of all Medicare and Medicaid recipients live.
The program focused primarily on home health agencies, nursing homes, and durable medical equipment Durable medical equipment is a term of art used to describe certain Medicare benefits, that is, whether Medicare may pay for the item. The item is defined by Title XVIII the Social Security Act:
In May 1997, the program was expanded to include 12 additional states. Eventually, the techniques developed by ORT investigators will be used in all 50 states and will be applied to all areas of Medicare and Medicaid spending.
Special initiatives. In March 1999, the Health Care Finance Administration said it intended to step up efforts to crack down on nursing homes that repeatedly violate health and safety requirements.(16) As part of that effort, the agency strengthened federal oversight of state enforcement of nursing home regulations and provided consumers with improved access to information about nursing homes through the Internet.
Increased enforcement is expected to come about primarily through the use of civil monetary penalties, which under new regulations would be much easier to impose on noncompliant nursing homes. The initiative has met with strong resistance from the nursing home industry, which in May 1999 filed a lawsuit to block implementation of the new monetary penalty enforcement rules.(17)
False Claims Act cases. The government has brought several cases under the act alleging improper billing for supplies and unnecessary or substandard care. These are useful guides for lawyers considering filing under the act.
An example of an improper billing case is a qui tam action recently filed in Ohio. It alleges that Deaconess dea·con·ess
1. A Protestant woman who assists the minister in various functions.
2. Used as a title prefixed to the surname of such a woman: Deaconess Brown.
Noun 1. Hospital and affiliated entities and physicians defrauded Medicare and Medicaid by engaging in "gang visits on nursing home residents," billing for services not performed, and providing inadequate patient care.(18)
According to the complaint, the defendants falsified medical records and charged for procedures not personally performed by the billing physicians but by nurses who routinely signed the physicians' names to records. The allegations also state that nurses adjusted doses of medication, including controlled substances, without first getting physicians' orders to do so.
An example of a case involving unnecessary care is one alleging that a Chicago nursing home's employees submitted false Medicare claims for psychological testing psychological testing
Use of tests to measure skill, knowledge, intelligence, capacities, or aptitudes and to make predictions about performance. Best known is the IQ test; other tests include achievement tests—designed to evaluate a student's grade or performance of unresponsive unresponsive Neurology adjective Referring to a total lack of response to neurologic stimuli and comatose co·ma·tose
1. Of, relating to, or affected with coma.
2. Marked by lethargy; torpid.
comatose (kō´m residents.(19) According to this complaint, the defendants knew the tests were not medically necessary.
The government also alleges that the testing took substantially less time to perform than the time billed to Medicare; that the defendants employed nonlicensed testers; and that these testers were told to conduct a second test, six months after the first, even though the residents' conditions had not changed.
Nursing Home Reform Act
Lawyers representing elderly clients who have been neglected or abused in nursing homes can use the False Claims Act to alert the government to substandard care in the facility. These cases use the act in conjunction with the Nursing Home Reform Act,(20) enacted as part of the Omnibus Budget Reconciliation Act of 1987.(21)
The Nursing Home Act requires nursing facilities to comply with federal requirements when providing services to patients.(22) It specifically requires that "[a] nursing facility must care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident."(23) Facilities must also "provide services and activities to attain or maintain the highest practicable physical, mental, and psychological well-being psychological well-being Research A nebulous legislative term intended to ensure that certain categories of lab animals, especially primates, don't 'go nuts' as a result of experimental design or conditions of each resident," which is to be done in accordance with individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. written care plans.(24)
The act specifies conditions under which restraints may be used on nursing home patients and establishes qualitative nutritional standards.(25) Regulations that have been promulgated prom·ul·gate
tr.v. prom·ul·gat·ed, prom·ul·gat·ing, prom·ul·gates
1. To make known (a decree, for example) by public declaration; announce officially. See Synonyms at announce.
2. under the act address the prevention and treatment of bedsores Bedsores Definition
Bedsores are also called decubitus ulcers, pressure ulcers, or pressure sores. These tender or inflamed patches develop when skin covering a weight-bearing part of the body is squeezed between bone and another body part, or a bed, , the treatment of urinary incontinence Urinary Incontinence Definition
Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it. , and the provision of naso-gastric tubes and hydration hydration /hy·dra·tion/ (hi-dra´shun) the absorption of or combination with water.
1. The addition of water to a chemical molecule without hydrolysis.
The act also prohibits discrimination against Medicaid beneficiaries. It says "a nursing facility must establish and maintain identical policies and practices regarding transfer, discharge, and covered services covered services,
n.pl the services for which payment is provided under the terms of the dental benefits contract.
a species that causes Q fever in man. under [Medicare and/or Medicaid] for all individuals regardless of source of payment."(27)
Moreover, Medicaid-eligible residents must be provided with necessary therapy regardless of whether the state's Medicaid program provides extra reimbursement for those services.(28) The law specifies that a person deciding whether to provide therapy in a nursing home cannot consider the source of reimbursement in making that decision.(29)
False Claims Act cases have been filed against nursing homes seeking to establish regulatory violations of the Nursing Home Act as the basis of violations of the False Claims Act. Liability is based on a certification signed by a nursing home administrator that says the home complied with all government regulations, including the Nursing Home Act.
By submitting the certification of compliance to the Health Care Finance Administration, the nursing facility represents that it has complied with the requirements of the Nursing Home Reform Act, and failure to do so makes any Medicaid claim for the cost of substandard care a false claim. When investigating a potential "substandard care" qui tam case, the attorney should look for evidence of widespread patient neglect, including physical abuse, inadequate staffing, lack of proper nutrition proper nutrition,
n in Tibetan medicine, a therapeutic concept that begins with a digestive formulation because it is believed that a medical condition is primarily the result of a nutritional dysfunction or disturbance in the process of delivering nutrients. , excessive patient falls, excessive use of restraints, malnourishment mal·nour·ish·ment
Malnutrition. , dehydration, and pressure sores.
An opinion holding that substandard care can be the basis for a False Claims Act case is United States ex rel ex rel. conj. abbreviation for Latin ex relatione, meaning "upon being related" or "upon information," used in the title of a legal proceeding filed by a state attorney general (or the federal Department of Justice) on behalf of the government, on the instigation of . Aranda v. Community Psychiatric Centers, Inc.(30) In that case, the government alleged that a psychiatric hospital psychiatric hospital
A hospital for the care and treatment of patients affected with acute or chronic mental illness. Also called mental hospital. violated the False Claims Act by filing claims for reimbursement while "knowingly failing to provide the government-insured patients with a reasonably safe environment.(31)
The government alleged that patients suffered physical injuries and sexual abuse because the defendant did not provide adequate staff, monitoring equipment, and appropriate housing assignments. Specifically, the complaint alleged that the facility failed to take adequate precautions to protect patients with suicidal or "elopement Elopement
with Dombey’s wife. [Br. Lit.: Dombey and Son]
with Alvaro, rejected as suitor by her father. [Ital. " tendencies and to protect patients from other physically aggressive patients.
In Aranda, liability was imposed based on the defendant's failure to meet professionally recognized standards in health care as required by 42 C.F.R. [sections] 455.2., a regulation promulgated pursuant to 42 U.S.C. [subsections] 1902 (a)(4), 1903 (i)(2), and 1909 of the Social Security Act. It prohibits fraud in the Medicaid program. The court rejected the defendant's claim that it could not knowingly violate such a vague standard.(32)
A series of four False Claims Act cases based on claims that nursing homes provided inadequate care have been brought and settled by the assistant U.S. attorney for the Eastern District of Pennsylvania. Allegations included failure to provide adequate nutrition, nursing care, monitoring of water temperature (scalding scalding
plunging of pig or poultry carcasses into very hot water to facilitate scraping and dehairing and plucking. Chicken scalding water is 130°F for broilers (larger birds higher) applied for 1 to 2 minutes. Modern pig abattoirs use steam at 144 to 147°F for about 3 minutes. ), and staffing.(33) As in the Aranda case, the government's theory of liability in the Pennsylvania cases was based on the nursing homes' certification that the provision of services or items for which payment was claimed comported with all federal and state laws and regulations.(34)
For example, one of the Pennsylvania cases, United States v. GMS GMS Greater Mekong Subregion
GMS Global Mobile (Communications) System
GMS Guild Management System
GMS General Medical Services
GMS Global Management System (Sonicwall)
GMS GroupWise Mobile Server Management-Tucker, was based on the allegation that the owner and operator of a nursing home had failed to provide required care to its residents.(35) Specifically, the government alleged that the nursing facility failed to provide adequate nutrition and wound care to residents.
The residents had developed decubitus ulcers Decubitus ulcers
A pressure sore resulting from ulceration of the skin occurring in persons confined to bed for long periods of time
Mentioned in: Immobilization and were malnourished mal·nour·ished
Affected by improper nutrition or an insufficient diet. to the point that their bodies could not heal from the ulcers. The government contended the claims for reimbursement that the facility submitted to Medicare were false because the services provided did not conform with the Nursing Home Act.
The four Pennsylvania cases resulted in monetary settlements of between $100,000 and $600,000, as well as a consent decree A settlement of a lawsuit or criminal case in which a person or company agrees to take specific actions without admitting fault or guilt for the situation that led to the lawsuit.
A consent decree is a settlement that is contained in a court order. requiring the homes to comply with the Nursing Home Act. Although these were not qui tam cases brought by private relators, they establish the viability of using the False Claims Act to prevent inadequate nursing home care.
Several other False Claims Act cases involving allegations of inadequate nursing home care have been filed outside of Pennsylvania. In September 1998, the Department of Justice announced that it intervened and simultaneously settled a qui tam suit alleging that a Maryland nursing home falsely certified compliance with federal laws requiring homes to meet certain standards of care Standards of care are medical or psychological treatment guidelines, and can be general or specific. They specify appropriate treatment protocols based on scientific evidence, and collaboration between medical and/or psychological professionals involved in the treatment of a given to participate in state and federally funded health care programs.(36) The Department of Health and Human Services, through the Health Care Finance Administration, closed down the facility in December 1998 and moved residents to other facilities.
The agency also barred the home from further participation in the Medicare program because of continuing concerns regarding the quality of care. The federal district court ruled that the agency had the authority to close the nursing home even though the home had signed a consent agreement with the Department of Justice providing that it would comply with all government regulations, including the Nursing Home Act.
The 24-page agreement specified that the nursing home would, among other things, appoint a temporary manager and an independent monitor, and would hire a certified nurse practitioner nurse practitioner
n. Abbr. NP
A registered nurse with special training for providing primary health care, including many tasks customarily performed by a physician. to ensure the well-being of residents. The court ruled that the agency was not bound by the terms of an agreement entered into by the Department of Justice.(37)
Another nursing home qui tam complaint that was unsealed in July 1998 alleges that 10 California homes violated the False Claims Act by neglecting residents, falsifying patient records, and submitting bills to Medicare and Medicaid with the knowledge that the homes had failed to satisfy federally mandated conditions of participation.(38)
The complaint alleges the homes violated the Nursing Home Act by failing to provide individualized personal hygiene personal hygiene person n → Körperhygiene f care plans for residents, adequate water, proper wound care, appropriate medications, or a safe environment. The DOJ declined to intervene in the action, which is pending.
In May 1999, the Department of Justice announced a settlement with Georgia-based Kansas Health Care Investors and Maryland-based Rehab Works, Inc. to resolve the allegations that the defendants falsely certified compliance with federal regulations regarding nursing home standards of care in order to receive Medicare reimbursement.(39) The homes allegedly provided inadequate nutrition inadequate nutrition Malnutrition, see there and unsanitary un·san·i·tar·y
Not sanitary. living conditions living conditions npl → condiciones fpl de vida
living conditions npl → conditions fpl de vie
living conditions living to residents and billed Medicare for physical, occupational, and speech pathology speech pathology
The science concerned with the diagnosis and treatment of functional and organic speech defects and disorders. Also called speech-language pathology. therapy services that were not medically necessary.
As these cases illustrate, the False Claims Act provides an effective means of preventing fraud and ensuring that nursing home patients are given the level of care required by federal law. Every dollar lost to fraud or abuse is a dollar that is not available to provide needed care to nursing home residents.
The benefits to individuals who bring these cases and win are threefold. In addition to the monetary compensation provided by law, relators and their lawyers can also reap the reward of knowing that they have helped to combat wrongful conduct Noun 1. wrongful conduct - activity that transgresses moral or civil law; "he denied any wrongdoing"
actus reus, misconduct, wrongdoing
activity - any specific behavior; "they avoided all recreational activity" while improving the lives of some of our most vulnerable citizens.
Fraud and abuse
Unfortunately, a significant portion of Medicare and Medicaid money is going into the pockets of unscrupulous heath care providers.
(1.) DEPARTMENT OF HEALTH & HUMAN SERVS SERVS Ship Escort Response Vessel System (Alyeska Pipeline Service Company) ., OPERATION RESTORE TRUST OBJECTIVES AND FIRST-YEAR ACCOMPLISHMENTS (May 13, 1996) (visited Oct. 22, 1999), http:// waisgate.hhs.gov/cgi-bin/waisgate.
(2.) The GAO reported that, in 1997, 11 percent ($20.3 billion) and, in 1998, 7.1 percent ($12.6 billion) of the federal health care budget was improperly paid due to fraud and abuse. DEPARTMENT OF JUSTICE, HEALTH CARE FRAUD REPORT: FISCAL YEAR 1998, 3 (visited Oct. 22, 1999), http://www. usdoj.gov/dag/health98.htm#toc [hereafter 1998 FRAUD REPORT].
(3.) 31 U.S.C. [subsections] 3729-3733 (1994).
(4.) 42 U.S.C. [subsections] 1396r, 1395i-3 (1994).
(5.) The False Claims Act is a complex statute. This brief overview is no substitute for a thorough reading of the statutory language and the case law interpreting that language, which may differ in the various federal circuit courts. See Jeffrey A. Lovitky, Qui Tam Litigation: A Practical Primer, TRIAL, Jan. 1999, at 68.
(6.) United States ex rel. Stinson, Lyons, Gerlin & Bustamante, P.A.v. Prudential Ins. Co., 944 F.2d 1149, 1152 n.2, 1153 (3d Cir. 1991).
(7.) 31 U.S.C. [sections] 3729(a)(1) (1994).
(8.) Id. at [sections] 3729(a)(2) (1994).
(9.) Id. at [sections] 3729(a)(3) (1994).
(10.) Id. at [sections] 3729(a)(7) (1994).
(11.) 1998 FRAUD REPORT, supra A relational DBMS from Cincom Systems, Inc., Cincinnati, OH (www.cincom.com) that runs on IBM mainframes and VAXs. It includes a query language and a program that automates the database design process. note 2, at 6.
(12.) 31 U.S.C. [sections] 3730(b)(2) (1994).
(13.) See M. [sections] 3730(d) (1994).
(14.) Publication of OIG Noun 1. OIG - the investigative arm of the Federal Trade Commission
Office of Inspector General
independent agency - an agency of the United States government that is created by an act of Congress and is independent of the executive departments Special Fraud Alert: Home Health Fraud, and Fraud and Abuse in the Provision of Medical Supplies to Nursing Facilities, 60 Fed. Reg. 40,847 (1995). The OIG stated, "Nursing facilities and their residents have become common targets for fraudulent schemes involving medical supplies. The OIG has become aware of a number of fraudulent arrangements by which medical suppliers profit from inappropriate business dealings in the name of unwilling nursing facility residents. Sometimes, nursing facility management and staff are also involved in these schemes." Id. at 40,849.
(15.) Publication of OIG Special Fraud Alert: Fraud and Abuse in the Provision of Services in Nursing Facilities, 61 Fed. Reg. 30,623 (1996).
(16.) HEALTH CARE FINANCING ADMIN., COMPREHENSIVE PLAN FOR PROGRAM INTEGRITY (Mar. 1999) (visited Oct. 22, 1999), http://www.hcfa. gov/medicare/fraud/cover.htm.
(17.) American Health American Health Inc. is a company that manufactures health supplements. It is located in Holbrook, New York. One of its products is labeled the "Chewable Original Papaya Enzyme" with the attached registered trademark, "The 'After Meal Supplement'". Care Ass'n v. Shalala, No. 1:99-CV-01207 (D.D.C. filed May 17, 1999), reported at 8 Health L. Rep. (BNA BNA Bureau of National Affairs, Inc.
BNA Birds of North America
BNA block numbering area (US Census)
BNA British North America
BNA Banco Nacional de Angola (National Bank of Angola) ) 857 (May 27, 1999). This same industry group has criticized use of the False Claims Act to detect and prevent poor patient care in nursing homes. The group has drafted proposed changes to what it says is a broken enforcement system. Enforcement Reform, (visited Oct. 22, 1999), http://www.ahca.org/brief/Enforcement%20Reform. htm.
(18.) United States ex rel. Martin v. Deaconess Ass'ns, Inc., No. C-1-96- 1164 (S.D. Ohio filed Dec. 16, 1996), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., Oct. 1998, at 34. Other "improper billing" cases include United States v. Medco Physicians Unlimited, No. 98C1622 (N.D. Ill. filed Mar. 19, 1998), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., July 1998, at 48; United States v. Horizon/CMS Healthcare Corp. (settled before filing), reported at 7 Health L. Rep. (BNA) 1011 (June 25, 1998).
(19.) U.S.v. Donaldson & Kaplan, No. 98C3881 (N.D. Ill. filed June 24, 1998), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., Oct. 1998, at 34. Other "unnecessary care" cases include United States Royal Geropsychiatric Servs., Inc., 8 F. Supp. 2d 690 (N.D. Ohio 1998); United States v. Transcor, Inc., No. 96C7373 (N.D. Ill. filed Nov. 12, 1996), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., Jan. 1997, at20.
(20.) 42 U.S.C. [sections] 1396r (1994).
(21.) Id. at [sections] 1359i-3 (1994).
(22.) Id. at [subsections] 1396r (b), 1395i-3 (b) (1994).
(23.) Id. at [subsections] 1396r (b)(1)(a), 1395i-3 (b)(1)(a) (1994).
(24.) Id. at [subsections] 1396r (b)(2)(a), 1395i-3 (b)(2)(a) (1994).
(25.) Id. at [subsections] 1396r(c)(1)(A)(ii), 1396r(b)(4)(A)(iv) (1994).
(26.) 42 C.F.R. [sections] 483.25 (1998).
(27.) 42 U.S.C. [subsections] 1395i-3(c)(4), 1396r(c)(4), 1396r(c)(4)(a) (1994); 42 C.F.R. [sections] 483.12(c)(1) (1994).
(28.) 42 C.F.R. [sections] 483.45(a)(1)(2) (1998).
(29.) 42 U.S.C. [subsections] 1395i-3(c)(4), 1396r(c)(4)(a) (1994) [equal access provision]; 42 C.F.R. [sections] 483.12(c) (1) (1998).
(30.) 945 F. Supp. 1485 (W.D. Okla. 1996).
(31.) Id. at 1487.
(32.) Id. at 1488.
(33.) United States v. GMS Management-Tucker, Inc., No. 96-1271 (E.D. Pa. filed Feb. 21, 1996), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., July 1996, at 31; United States v. Chester Care Ctr., No. 98-CV-139 (E.D. Pa. filed Jan. 13, 1998), reported at 7 Health L. Rep. (BNA) 162 (Jan. 29, 1998); United States v. Philadelphia, No. 98-4253 (E.D. Pa.), reported at 7 Health L. Rep. (BNA) 1494 (Sept. 24, 1998); United States v. Integrated Health Servs. at Penn, Inc. (E.D. Pa. settled before filing), reported at 8 Health L. Rep. (BNA) 857 (May 27, 1999).
(34.) See David R. Hoffman, The Federal False Claims Act as a Remedy to Poor Care, FALSE CLAIMS ACT & QUI TAM Q. REV., July 1996, at 31.
(35.) GMS Management-Tucker, Inc., No. 96-1271.
(36.) United States v. Greenbelt Nursing & Rehabilitation (D. Md. filed Sept. 14, 1998), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., Oct. 1998, at 39.
(37.) See Northern Health Facilities, Inc. d/b/a Greenbelt Nursing & Rehabilitation Ctr. v. United States, No. AW-98-4006 (D. Md. Dec. 28, 1998), reported at 8 Health L. Rep. (BNA) 18 (Jan. 7, 1999).
(38.) United States ex rel. McKenzie & Swan v. Crestwood Hosps., Inc., No. CIV-5-97-0107 (E.D. Cal. filed Jan. 22, 1997), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., Oct. 1998, at 45.
(39.) No. 96-1427-WEB (D. Kan. filed Nov. 26, 1996), reported at FALSE CLAIMS ACT & QUI TAM Q. REV., July 1999, at 34. The case settled for more than $800,000.
John M. Parisi practices law in Overland Park, Kansas Overland Park is the second most populous city in the U.S. state of Kansas. It is located in Johnson County, a satellite city of Kansas City, and is near Olathe, Lenexa, Prairie Village and Leawood. In 2006, the estimated population is 167,500. .