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Bronx nursing center frauds Medicare payments

Damian Williams, U.S. Attorney for the Southern District of New York, and Scott J. Lampert, Special Agent in charge of the New York Regional Office of the U.S. Department of Health and Human Services, Office of the Inspector General ( “HHS-OIG”), announced today that the United States has filed and resolved a civil lawsuit for health fraud against TCPRNC, LLC d / b / a PLAZA REHAB AND NURSING CENTER (“PLAZA REHAB CENTER”) and CITADEL CONSULTING GROUP LLC d / b / a CITADEL CARE CENTERS LLC (“CITADEL”). The lawsuit alleges that PLAZA REHAB CENTER, acting under the direction of CITADEL, fraudulently changed the type of Medicare coverage in which senior residents were enrolled in order to maximize the Medicare payments that PLAZA REHAB CENTER would receive. As alleged in the Government’s complaint, residents and their families often did not request, consent to or know about the change in their health coverage, which could affect their out-of-pocket payments, the scope of the covered services and care and your drug coverage plan.

U.S. Attorney Damian Williams said, “Residents of specialty nursing facilities have the right to choose their own health insurance coverage. The Plaza Rehab Center often changed the insurance of its residents without the their consent or knowledge, and without explaining how the change could affect their out-of-pocket costs and the scope of their health coverage.When facilities illegally take advantage of elderly residents to maximize their income of federal health care programs, this Office will hold them accountable. ”

HHS-OIG Special Agent Scott J. Lampert said, “HHS-OIG is committed to protecting Medicare and its beneficiaries from fraud. Those who exploit federal health care programs for benefits and violate the trust of the beneficiaries must be held accountable for their actions. ”

Under the agreement, which was approved on June 27, 2022 by U.S. District Judge George B. Daniels, PLAZA REHAB CENTER and CITADEL agreed to pay a total of $ 7.85 million and made large admissions of facts about his conduct. Specifically, PLAZA REHAB CENTER and CITADEL admitted that their staff often did not obtain the consent of the resident or their authorized representatives before unsubscribing the resident from their Medicare Advantage Plan. In addition, as part of the agreement, CITADEL agreed to take steps to ensure that all specialized nursing facilities that are Citadel care centers comply with the applicable guidelines on sick leave and health plan enrollments. Medicare. PLAZA REHAB CENTER and CITADEL also signed a corporate integrity agreement with HHS-OIG, which requires them to maintain a compliance program designed to encourage adherence to the requirements of the federal health care program and therefore protect the programs. .

Medicare beneficiaries can enroll in original Medicare parts, known as original Medicare, or Medicare Advantage plans, which are administered by private companies that contract with the government. The original Medicare and Medicare Advantage plans differ in the way health care providers, including specialty nursing facilities, seek out and receive reimbursement. Under Original Medicare, Medicare and Medicaid Service Centers (“CMSs”) reimburse providers directly, such as specialty nursing facilities, at a fee per service. In contrast, when providing medical services to a Medicare beneficiary enrolled in a Medicare Advantage plan, the provider files claims with the Medicare Advantage organization (“MAO”) that manages the Medicare Advantage Plan, which in turn pays the provider an amount. agreed. . CMS pays MAOs a fixed, per capita amount each month to provide coverage to Medicare beneficiaries enrolled in the Medicare Advantage Plan. CMS advises people to consider several factors when deciding between an original Medicare Advantage plan and Medicare, such as differences in out-of-pocket costs and physician choice.

As alleged in the complaint filed in federal court in Manhattan:

It is well known in the specialty nursing facilities industry that it is typically more cost effective to admit residents enrolled in Original Medicare than residents enrolled in Medicare Advantage plans. From September 2016 to February 2019, CITADEL lobbied PLAZA REHAB CENTER staff to increase the number of Original Medicare enrolled residents in order to increase Medicare reimbursements. PLAZA REHAB CENTER staff unsubscribed many residents from their self-selected Medicare Advantage plans and enrolled them in Original Medicare without obtaining the consent of residents or their authorized representatives.

PLAZA REHAB CENTER staff were supposed to ensure that residents (or their authorized representatives) signed “discharge forms” before making any discharge from the resident from their Medicare Advantage plan. However, in many cases, PLAZA REHAB CENTER staff unsubscribed residents from their Medicare Advantage Plan and enrolled them in Original Medicare without obtaining a signed termination form that reflected the resident’s consent. In fact, PLAZA REHAB CENTER employees made numerous layoffs without ever talking to the resident or their authorized representative or explaining the consequences of switching to Original Medicare. In addition, in other cases, the staff of the PLAZA REHABILITY CENTER discussed a discharge with the resident and allegedly obtained the resident’s consent, but the resident did not have the capacity to give consent due to his state of health. .

In the liquidation agreement, PLAZA REHAB CENTER and CITADEL admit, acknowledge and accept responsibility for the following conduct:

PLAZA REHAB CENTER staff, under the direction and pressure of a CITADEL manager responsible for new admissions practices, changed PLAZA REHAB CENTER resident insurance from Medicare Advantage Plans to original Medicare after admission of these residents in PLAZA REHAB CENTER. Among other things, CITADEL established a monthly termination fee for PLAZA REHAB CENTER and identified possible candidates for termination. PLAZA REHAB CENTER earned more income for residents if those residents were enrolled in Original Medicare, compared to Medicare Advantage plans. PLAZA REHAB CENTER staff often did not obtain the consent of the resident or their authorized legal representatives before unsubscribing the resident from their Medicare Advantage plan and enrolling them in Original Medicare. In approximately 19 cases, PLAZA REHAB CENTER staff allegedly obtained the consent of the residents before unsubscribing them from their Medicare Advantage plan, but, according to the assessments of the mental state of these residents, they did not have the capacity to give consent because of his state of health. PLAZA REHAB CENTER regularly did not take into account the results of these mental health assessments and did not assess the ability of residents to consent to the change of insurance. PLAZA REHAB CENTER staff made these changes to a resident’s coverage by logging into the website using the resident’s personal information. PLAZA REHAB CENTER staff would use this website to unsubscribe the resident from their self-selected Medicare prescription drug plan, which caused the resident to be automatically unsubscribed from their self-selected Medicare Advantage Plan. and enroll in Original Medicare. In some cases, upon completing the online information to unsubscribe, PLAZA REHAB CENTER staff misrepresented that they were: (i) the person listed on the registration form; (ii) a person who assists the person indicated on the registration form to complete the form; or (iii) a person authorized to act on behalf of the person on the registration form in accordance with the laws of the state in which the person resided. PLAZA REHAB CENTER and CITADEL often did not offer assistance to Plaza Rehab Center residents to re-enroll them in a Medicare Advantage plan after discharge from the Plaza Rehab Center facility. As a result of the conduct described above, the government made payments under Original Medicare to PLAZA REHAB CENTER for residents who were incorrectly enrolled in Original Medicare without their consent. PLAZA REHAB CENTER was not entitled to these payments.

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