Patients staying in skilled nursing facilities, or their
insurers such as Medicare, pay a bundled payment to these facilities that cover
all of a patient’s needs, including such items as splints, and thus no separate
Medicare reimbursement for such devices is permitted.
To circumvent Medicare rules, defendants allegedly mispresented that patients were in their homes or other places that were not skilled nursing facilities. Thus, the government alleged that Hepburn and Dynasplint knowingly mischarged Medicare for splints used by patients in Medicare-certified SNFs.
To circumvent Medicare rules, defendants allegedly mispresented that patients were in their homes or other places that were not skilled nursing facilities. Thus, the government alleged that Hepburn and Dynasplint knowingly mischarged Medicare for splints used by patients in Medicare-certified SNFs.
The
settlement resolves allegations originally brought in a lawsuit filed by
Meredith Deane, a former sales executive for Dynasplint, under the
whistleblower, or qui tam, provisions of the False Claims Act, which
allow private parties to bring suit on behalf of the government and to share in
any recovery.
The United States may intervene in such an action as it did here. Ms. Deane and her counsel will receive at least $1.98 million for the settlement.
The United States may intervene in such an action as it did here. Ms. Deane and her counsel will receive at least $1.98 million for the settlement.
In August 2013, the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) suspended payments to Dynasplint based upon the allegations in the lawsuit which it found to contain credible allegations of fraud in the claims and billing. As part of the settlement, defendants are agreeing to forfeit all funds held by this payment suspension, approximately $8.5 million.
The
lawsuit is captioned U.S. ex rel. Deane v. Dynasplint Health Systems, Inc.
and George Hepburn, Case No. 10-cv-2085 (E.D. La.). The claims
resolved by this settlement are allegations only and there has been no
determination of liability.
Attorney Commentary: It is always easy after the fact to see how an arrangement like this will be a problem after the fact. This is a situation where it seems the SNF knew or should have known or encouraged this type of billing arrangement in order for them to save on their own costs. The splints were provided but then the indication on the claim is that the patient is located somewhere other than the SNF even though Medicare should be able to tell the patient is in a SNF. What an expensive business model.
We tell clients that billings do not matter when you can be subject to repayment years later. If the business model does not work under the rules and regulations, it is not worth having to pay back the entire amount years later, be subject to lawsuits or to even criminal allegations of Medicare fraud. Think big picture and if there are compliance issues, fix them now.
Posted by Tracy Green, Esq.
Office: 213-233-2261
Attorney Commentary: It is always easy after the fact to see how an arrangement like this will be a problem after the fact. This is a situation where it seems the SNF knew or should have known or encouraged this type of billing arrangement in order for them to save on their own costs. The splints were provided but then the indication on the claim is that the patient is located somewhere other than the SNF even though Medicare should be able to tell the patient is in a SNF. What an expensive business model.
We tell clients that billings do not matter when you can be subject to repayment years later. If the business model does not work under the rules and regulations, it is not worth having to pay back the entire amount years later, be subject to lawsuits or to even criminal allegations of Medicare fraud. Think big picture and if there are compliance issues, fix them now.
Posted by Tracy Green, Esq.
Office: 213-233-2261
