N.Y. U.S. Attorney Announces $7.85M Settlement With Citadel Skilled Nursing Facility in Bronx for Fraudulently Switching Residents Healthcare Coverage to Boost Medicare Payments
HHS-OIG Special Agent-in-Charge
Under the settlement, which was approved on
Medicare beneficiaries may enroll in the original parts of Medicare, known as Original Medicare, or in Medicare Advantage Plans, which are administered by private companies that contract with the government. Original Medicare and Medicare Advantage Plans differ in how healthcare providers, including skilled nursing facilities, seek and receive reimbursement. Under Original Medicare, the
As alleged in the Complaint filed in
It is well known within the skilled nursing facility industry that it is typically more profitable to admit residents who are enrolled in Original Medicare than residents enrolled in Medicare Advantage Plans. From
PLAZA REHAB CENTER staff were supposed to ensure that residents (or their authorized representatives) signed "disenrollment forms" prior to effectuating any disenrollment of the resident from their Medicare Advantage Plan. However, in many instances, PLAZA REHAB CENTER staff disenrolled residents from their Medicare Advantage Plan and enrolled them in Original Medicare without obtaining a signed disenrollment form reflecting the resident's consent. Indeed, PLAZA REHAB CENTER employees effectuated numerous disenrollments without ever speaking to the resident or their authorized representative or explaining the consequences of switching to Original Medicare. In addition, in other instances, PLAZA REHAB CENTER staff discussed a disenrollment with the resident and purportedly obtained the resident's consent, but the resident did not have the capacity to provide consent because of their health condition.
In the settlement agreement, PLAZA REHAB CENTER and
* PLAZA REHAB CENTER staff, at the direction and under pressure from a
* PLAZA REHAB CENTER staff often did not obtain the consent of the resident or their authorized legal representatives prior to disenrolling the resident from their Medicare Advantage Plan and enrolling them in Original Medicare.
* In approximately 19 instances, PLAZA REHAB CENTER staff purportedly obtained the residents' consent before disenrolling them from their Medicare Advantage Plan, but, according to these residents' mental status assessments, they did not have the capacity to provide consent because of their health condition. PLAZA REHAB CENTER regularly failed to consider the results of these mental health assessments and did not evaluate the capacity of residents to consent to the insurance change.
* PLAZA REHAB CENTER staff effectuated these changes in a resident's coverage by logging on to the Medicare.gov website using the resident's personal information. PLAZA REHAB CENTER staff would use this website to disenroll the resident from their self-selected Medicare prescription drug plan, which resulted in the resident automatically being disenrolled from their self-selected Medicare Advantage Plan and being enrolled into Original Medicare. In some instances, when completing the information online to effectuate the disenrollment, PLAZA REHAB CENTER staff misrepresented that they were either: (i) the person listed on the enrollment form; (ii) a person helping the person listed on the enrollment form in completing the form; or (iii) a person authorized to act on behalf of the individual on the enrollment form under the laws of the State where the individual resided.
* PLAZA REHAB CENTER and
* As a result of the conduct described above, the Government made payments under Original Medicare to PLAZA REHAB CENTER for residents who were improperly enrolled in Original Medicare without their consent. PLAZA REHAB CENTER was not entitled to these payments.
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In connection with the filing of the lawsuit and settlement, the Government joined a private whistleblower lawsuit that had previously been filed under seal pursuant to the False Claims Act.
This case is being handled by the Office's Civil Frauds Unit. Assistant
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Original text here: https://www.justice.gov/usao-sdny/pr/us-attorney-announces-785-million-settlement-citadel-skilled-nursing-facility-bronx
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