Many nursing homes operate ethically and do what they can to provide the proper care to the residents living there. There are some nursing homes, however, that do not provide the proper care and go out of their way to bill Medicare or Medicaid as much as they possibly can get away with.
When a law firm is in the process of prosecuting a nursing home for negligence, they also need to understand the correlation between negligent care and billing fraud.
It is a requirement that every nursing home is to prepare something called a “Minimum Data Set” (MDS). The MDS is an assessment that is done that gives a report on each resident in the home and their health issues and functional capabilities. An MDS is required for each resident in the home and must be prepared when a resident arrives in the nursing home. These assessments are also to be updated regularly. “Care area assessments” are to be done as part of the MDS process and help to develop an individual care plan for each resident.
Nursing homes are reimbursed by Medicare based on the MDS sheets. Medicare will review the MDS assessments and pay out based on how complex the needs of the residents are. The idea behind this is for the nursing home to take the extra funds that Medicare provides to then use those funds to maximize the care that the resident is getting. The problem is, this does not always happen. Despite the nursing home requesting help from Medicare, and receiving it, the nursing home will fail to provide the extra care to that resident. This failure can often result in injury or death to the resident.
Knowing how Medicare and the MDS process works is an essential part of of being able to successfully prosecute nursing home negligence. Being uncertain on how to prove that the nursing home was the one who originally claimed that a certain level of care was needed for a resident was necessary, then that nursing home may be able to deny any claims that care is the issue.
Nursing home cases of elder abuse in Florida are also frequently investigated for fraudulent Medicare or Medicaid claims as well. This is a serious issue that has become an eye-opening issue thanks to whistle-blowers and investigative journalism.