Since 2009, government funds available for The Health Care Fraud and Abuse Control Account have more than doubled — going from $465 million to more than $963 million. Funds dedicated for Department of Justice (DOJ) investigations have more than tripled from $198 million to $681 million. That said, Long-Term Care (LTC) facilities and providers must be equipped to defend against DOJ and Office of Inspector General (OIG) investigations of Medicare/Medicaid fraud, allegations of “worthless care,” allegations related to the False Claims Act, and other similar investigations still in litigation. ALN Consulting has extensive experience in delivering results for firms facing these investigations.

During an investigation, LTC facilities and providers need seasoned nurse experts, who can review care and uncover demonstrative evidence that shows whether a patient’s care was optimal. ALN Consulting nurse reviewers can help your team defend against DOJ and OIG investigations of fraud, false claims and worthless care allegations.

In one case, the United States claimed $18, 710, 000 in damages for Medicare and Medicaid failure. ALN Consulting nurses stepped in to examine the care 28 residents in 5 facilities to determine evidence of excellent care and refute allegations. During this review, ALN Consulting nurses probed Pre-Admission Evaluations (PAE) and Pre-Admission Screening and Resident Review (PASRR) in multiple facilities. The results revealed only 36 percent of the cases were assessed damages by the government after ALN nurse reviewers created demonstrative evidence of care. By implementing the ALN Consulting team, it reduced the damages to 20 of the PAE’s and 6 of the PASRR cases.

“In recent years, in part through the Affordable Care Act, the Department of Justice and the Centers for Medicare and Medicaid Services has attempted to refocus efforts on identifying and stopping Medicare fraud,” Gregory Stevens, a professor at the University of Southern California who specializes in health care reform and policy, told the Louisiana Record. “And each year, tens, if not hundreds, of individual physicians are singled out and prosecuted.”

“It is often difficult to clearly establish that what was billed to Medicare inaccurately was done so intentionally,” Stevens said. “Billing is complex and even well-meaning providers can have a pattern of billing Medicare that is not accurate.”

When reviewing allegations of worthless care, ALN Consulting looks at the overall care provided rather than analyzing specific events or breaches from standard care or level of harm — taking a much broader approach than those of typical litigation.

In one particular investigation, the ALN Consulting reviewers looked at medical records to determine whether worthless care was provided to a resident of a LTC facility. In this case, the DOJ/OIG made allegations of worthless care related to a resident’s poor hygiene, medication errors and poor nutrition. After reviewing records — while they did show some evidence of failures to care plans, omissions to medication administration and evidence of bed baths rather than showers — the overall record proved consistent care was provided.