The Grand Health Care System to Pay $21.3M for Allegedly Providing and Billing for Fraudulent Rehabilitation Therapy Services
Crime
The settlement resolves allegations that, from as early as Jan. 1, 2014, to Sept. 30, 2019, the Grand knowingly submitted false claims for rehabilitation therapy for residents at 12 facilities Strauss Ventures owned and operated. During this period, Medicare Part A (Medicare’s hospital insurance, which also pays for care in a skilled nursing facility in some circumstances) and TRICARE (the federal health care program for the Department of Defense) paid for such services at rates that varied based on the number of minutes of skilled rehabilitation therapy provided.
The Grand allegedly submitted bills where the reimbursement claimed was based on providing more therapy than was reasonable and necessary, or in some cases where the therapists did not provide the amount of therapy reported.
As part of the settlement, the Grand admitted that certain now-former Grand management level employees implemented quotas that each of the 12 facilities was expected to reach, including quotas relating to beneficiaries’ lengths of stay and to the percentage of beneficiaries billed at the highest reimbursement level. To meet these quotas, facilities often scheduled patients to receive therapy without consideration of what was reasonable and necessary based on the individual patients’ clinical condition.
In addition, the Grand directed that no more than three patients be discharged from any facility per week and instructed that no Medicare Part A patients should be discharged from rehabilitation therapy unless it had been discussed with corporate officials. The Grand admitted that this resulted in some Medicare beneficiaries “staying on therapy longer than was reasonable and medically necessary.”
The Grand acknowledged that there were various instances where supervisory officials, who did not personally evaluate or treat patients, set or adjusted the number of minutes of therapy that a Medicare patient would receive. The Grand also acknowledged that there were instances where supervisory personnel falsified the number of therapy minutes in the Grand’s electronic recordkeeping system or instructed subordinates to do so, well after the therapy was allegedly rendered.
The settlement also resolves federal allegations that the Grand submitted false claims to Medicaid for services rendered at its Pawling, New York, nursing home between Jan. 1, 2016, and June 30, 2021. These claims were allegedly false because the reimbursement rate was inflated by data inaccurately reflecting the degree of care, including rehabilitation therapy services, needed by Medicaid patients there.
The Grand has also entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General (HHS-OIG) that requires an independent review organization to annually assess the medical necessity and appropriateness of therapy services billed to Medicare.
The settlement resolves a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Stacey Rosenberger and Kelley Retig, former providers of rehabilitation therapy at the Grand. The Act allows private persons to file civil actions on behalf of the government and share in any recovery. Under the settlement, the whistleblowers will receive approximately $4,047,000 of the settlement proceeds. The case is captioned United States ex rel. Rosenberger and Retig v. Strauss Ventures, LLC, et al., No. 1:19-cv-1311 (N.D.N.Y.).
The U.S. Attorney’s Office for the Northern District of New York; the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section; HHS-OIG’s New York Region; the FBI Albany Field Office; DCIS, Syracuse Resident Agency and the New York State Attorney General’s Office investigated the matter.
Senior Trial Counsel Christelle Klovers of the Civil Division's Commercial Litigation Branch, Fraud Section and Assistant U.S. Attorney Adam J. Katz for the Northern District of New York prosecuted the case.