Maine Nursing Home Operator to Pay $300,000 to Resolve Allegations Concerning Claims for Rehabilitation Therapy
BOSTON—A skilled nursing facility operator in Maine, Rousseau Management, Inc., entered into an agreement with the United States to pay $300,000 to resolve allegations concerning inflated Medicare claims.
Rousseau, which owns the Horizons Living and Rehab Center in Brunswick, Maine, and previously provided administrative management services to the Amenity Manor skilled nursing facility in Topsham, Maine, entered into an agreement concerning claims for therapy purportedly provided by its subcontractor, RehabCare Group East, Inc. (RehabCare), a part of Kindred Healthcare, Inc. This settlement resolves allegations that Rousseau submitted, or caused the submission of, claims to Medicare that sought inflated amounts of reimbursement based on the provision of unreasonable, unnecessary, unskilled rehabilitation therapy, or therapy that was not provided at all.
“This settlement is another in a series of resolutions involving inflated Medicare billing at skilled nursing facilities,” said United States Attorney Carmen M. Ortiz. “We continue our efforts to ensure that the provision of care in nursing facilities is based on patients’ clinical needs and not tied to the inflated financial interests of the companies providing care.”
“These defendants allegedly made decisions based on profitability, rather than on patient care,” said Vincent B. Lisi, Special Agent in Charge of the Federal Bureau of Investigation, Boston Field Division. “These actions not only affect patients, but have a ripple effect on taxpayers who pay into the system. The FBI will continue to work with all of our law enforcement partners to make sure those who abuse the healthcare system are brought to justice.”
The United States alleges that prior to Oct. 1, 2011, Rousseau failed to take sufficient steps to prevent RehabCare from engaging in a pattern and practice of providing high levels of therapy that were not reasonable or necessary during so-called “assessment reference periods,” thereby causing Horizons and Amenity Manor to bill for their Medicare patients’ care at the highest reimbursement level, even though RehabCare was providing less therapy to those same patients during those periods when the facilities were not required to report to Medicare the amount of therapy their Medicare patients were receiving.
This settlement further resolves allegations that, even after Oct. 1, 2011, Rousseau failed to prevent other RehabCare practices designed to inflate Medicare reimbursement, including: (1) presumptively placing patients in the highest reimbursement level unless it was shown that the patients could not tolerate that amount of therapy, rather than using individualized evaluations to determine the level of care most suitable for each patient’s clinical needs; (2) planning the minimum number of minutes of therapy required to bill at the highest reimbursement level while discouraging the provision of therapy in amounts beyond that minimum threshold, despite the Medicare requirement that the amount of care provided be determined by patients’ clinical needs; (3) arbitrarily shifting the number of minutes of planned therapy between therapy disciplines to ensure targeted reimbursement levels were achieved; (4) reporting that time spent on initial evaluations was therapy time in order to avoid the Medicare prohibition on counting initial evaluation time as therapy time; and (5) reporting that time spent providing unskilled palliative care was time spent on skilled therapy.
The government encourages anyone with information about the practices described above, or similar practices involving rehabilitation therapy in nursing facilities, to contact the Department of Health and Human Services Office of Inspector General Hotline via telephone, 1-800-HHS-TIPS (1-800-447-8477), or in writing via https://forms.oig.hhs.gov/hotlineoperations/.
This matter was investigated by the Department of Health and Human Services, Office of the Inspector General, and the Federal Bureau of Investigation. The case was handled by Assistant U.S. Attorneys Gregg Shapiro and Patrick Callahan of Ortiz’s Affirmative Civil Enforcement Unit and Department of Justice Trial Attorneys Christelle Klovers and Rohith Srinivas.