According to Medicare fraud reports by the U.S. Department of Human Health and Services (HHS), the U.S. Department of Justice’s Medicare Fraud Strike Force team has investigated $7 billion in fraudulent billing since 2007 and prosecuted over 2400 medical professionals and administrators. Part of that amount comes from nursing homes that bill for unnecessary services or for services that have not been provided to the residents that depend on them.

And that fraudulent activity harms nursing home residents as well as our government’s bottom line.

How do you combat that kind of fraud? It starts with CNAs, LPNs and other healthcare staff on the front lines that have witnessed or can provide documentation that the facility is billing for unnecessary care, or is not providing the care for which it bills to Medicare and Medicaid. Because those front-line care providers have pride in how they do their jobs, they have incentive to ensure that they can provide their patients with the best care possible.

To help ensure that patients receive proper services, the federal False Claims Act (FCA) permits healthcare workers and other citizens to help the government catch and stop fraud. People who help the government catch and stop fraud are known as “whistleblowers.” After settling a fraud case, the FCA allows the government to share a piece of the recovery amount with the whistleblower.

Beyond the financial incentive, whistleblowers can make sure people in nursing homes get the care they need, and protect them from harm. There are two ways that you, as a healthcare provider, can make a difference:

1. Call the HHS which oversees nursing homes, conducts inspections, and writes citations, so they can help convince providers to do a better job; or

2. Act as an agent for the government (in partnership with a lawyer) to file a fraud claim under the FCA. The only way to properly file the correct documents and complaint is through a lawyer.

   • Once a complaint is filed, the government will decide if it wants to intervene and take over the lawsuit for you. You can still pursue the case with your lawyer on your own if the government declines—but they get first crack at the case. Incentives for reporting fraud include:

     • A percentage of the recovery amount; and

     • The ability to help people and improve quality of care.

   • An employer could fire a whistleblower, but there are significant disincentives including

     • Paying you double damages in a lawsuit; and

     • Paying you double back pay.

The FCA makes a world of difference in protecting people in nursing homes. A recent case against nursing home giant ManorCare, Inc. cited they were “subjecting seniors to unnecessary and sometimes harmful care” as part of $6 billion in billing (ManorCare).

The suit, which is now being prosecuted by the government, accuses ManorCare of converting the majority of its residents—at least on paper—to what’s called an “Ultra High” level of care even if not prescribed. In one case they were giving an 84 year old man intensive therapy even though his doctor had ordered he only receive pain management during his last days.