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Nursing Home Fraud Whistleblowers

Blowing the whistle on nursing homes that abuse Medicare, Medicaid, and TRICARE.

Do you suspect fraud?

The elderly are some of the most vulnerable people in our society. They are also an easy target for scammers. This type of fraud is so prevalent that the National Council on Aging calls scams targeting seniors “the crime of the 21st century,” and number one on that list is Medicare/Medicaid and other healthcare fraud.

When you think of the kind of person that would defraud the elderly, your mind may conjure up images of smooth talkers on the phone or shady people behind computer screens convincing a trusting senior to give up private information.

But what if the senior scammers, fraudsters, and thieves are some of the nursing home corporations who promise to care for them?

And it’s not just our elders who are victims in this case. Medicare, Medicaid, and TRICARE (military healthcare benefits) are programs funded by taxpayer dollars, so millions of taxpayers like you who give up a part of every paycheck towards taxes are gravely affected by such dishonesty.

Qui Tam whistleblower claims against for-profit nursing homes

About 69.3% of nursing homes in the U.S. are for-profit, according to a recent study by the CDC – many of these are chains owned by large corporations. Who is keeping track of the quality of care at nursing homes and making sure they are accountable for their Medicare, Medicaid, and TRICARE billings? Who is making sure that the giant billion-dollar corporations that run for-profit nursing home chains are accurately and fairly charging the government for the services they tell the government they are providing for their residents?

The only person who may be able to hold fraudsters accountable in these cases is you.

If you work (or used to work) in a nursing home – whether you’re an administrator, someone who works in billing, a physical therapist, a nurse, or anyone else who witnessed or knew about the facility’s wrongdoing – we are here to help you to try to stop the fraud. When corporations or facilities misrepresent the condition of patients simply to extract more (taxpayer) money, we support honest whistleblowers who choose to report this conduct to the government.

And when you blow the whistle on corrupt nursing homes, we will work hard to try to stop their wrongdoing.

If your nursing home is involved with the kinds of fraud discussed below, please call Carolina Whistleblower Attorneys at 1-888-292-8852 or send us a message to have us call you.

What Medicare, Medicaid, and TRICARE fraud in nursing homes may look like

Regulatory agencies – and the government as a whole – have many things to keep an eye on, and they are often understaffed and underfunded. In the absence of oversight, fraud can thrive. Here are just a few of the ways nursing home fraud can manifest, according to the National Whistleblower Center:

  • Billing Medicare and/or Medicaid for services not performed
  • Failure to comply with “best pricing” in the Medicaid program
  • Failure to properly enroll qualified patients in a Medicaid sponsored program
  • Paying kickbacks to have doctors, hospitals, or other care-givers prescribe certain drugs or otherwise bill Medicare and/or Medicaid
  • Billing for services provided to ineligible persons
  • Defective or illegal pricing of drugs
  • Illegal or improper marketing of drugs
  • Overcharging at pharmacies
  • Performing unnecessary medical treatments
  • Improper referrals or self-dealing
  • Violations of various rules, such as the Stark Act, the Anti-Kickback Act, and the Best Pricings laws
  • Knowingly presenting (or causing to be presented) to the federal government a false or fraudulent Medicare and/or Medicaid claim for payment
  • Knowingly using (or causing to be used) a false record or statement to get a Medicare or Medicaid claim paid by the federal government
  • Conspiring with others to get a false or fraudulent Medicare or Medicaid claim paid by the federal government

Nursing home fraud in the Carolinas

From 2013 to 2017, Saber Healthcare Group reportedly required directors and therapists at their nursing home facilities in North Carolina and other states to commit systemic fraud. Saber allegedly told their employees to place all newly admitted residents into the “ultra high” category of the now-outdated Resource Utilization Group (the category that brought the most Medicare reimbursement for nursing homes). This was directly contrary to Medicare regulations that state it covers only what is “reasonable and necessary for the diagnosis or treatment of illness or injury.”

The Saber whistleblowers, or the “relators,” claimed that even if the residents did not need or could not tolerate therapy at that level, they were still instructed by the facility to categorize residents at that level. Moreover, some of the therapy services they provided were unrelated to that individual’s medical needs.

Saber settled for $10 million rather than have the federal government pursue a verdict. The three whistleblowers who alerted the U.S. government of the wrongdoings were awarded with $1.75 million of that settlement,1 and Saber will be required to submit to reviews of their Medicare billings and transactions in the coming years.3

Fraudulent billings to the government occur far too often in South Carolina, too. In one recent case, an owner of six nursing homes defrauded state Medicaid for more than $1 million in overpayment over two years.3 Those were your taxpayer dollars, dollars that should go to provide real nursing home care to seniors who can’t otherwise afford it.

Nursing home chains who have settled qui tam cases

Fraudulent government billing by nursing homes – often among chains run by faceless mega-corporations – is rampant. Here are some cases of nursing home chains and their parent companies that have settled claims3 after being outed by a whistleblower:

  • In October 2016, Life Care Centers of America Inc. agreed to a $145 million settlement to resolve False Claims Act allegations related to the improper classification of patients in rehabilitation therapy. The whistleblower reward was $29 million.1
  • In January 2016, RehabCare Group Inc. and related entities agreed to pay a $125 million settlement to resolve allegations that they fraudulently inflated reimbursement levels and kept patients in therapy longer than necessary. The whistleblowers received nearly $24 million.1
  • In March 2013, Grace Healthcare LLC and its affiliate agreed to pay $2.7 million to resolve allegations that they knowingly submitted false or fraudulent claims for skilled nursing services to Medicaid and Medicare.
  • In June 2021, Plum Healthcare Group LLC and Azalea Holdings LLC resolved allegations that they knowingly created billing records for services that were not actually provided by paying more than $450,000.

Qui Tam Claim Basics

When there is fraudulent use of taxpayer/government money, a whistleblower claim is called a qui tam claim, and the law that protects whistleblowers in qui tam claims is called the False Claims Act, or the FCA. There can be major financial incentives for a successful claim.

The federal False Claims Act and North Carolina False Claims Act both impose treble (or triple) damages on culpable defendants. These are what would protect you and allow you to bring a qui tam claim against your nursing home. With a nursing home whistleblower claim, you could receive up to 30% of the government’s recovery if your case succeeds.

How much you ultimately may receive depends on many factors, including:

  • The quality of the information you provide — the more detailed and extensive the information, the more your potential reward
  • How much assistance you provide in the case
  • Whether the case involves a significant public safety issue

Carolina Whistleblower Lawyers Are Here to Try to Keep Nursing Homes Accountable for Medicare, Medicaid, and TRICARE Fraud

We stand ready to help all potential whistleblowers who want to put an end to fraudulent practices, even those who may have some hesitations due to financial concerns. We want you to know that you will not be alone, and a successful claim can bring about great rewards. There is a time limit in which one can successfully report fraudulent behavior, so please don’t wait to call us.

Put your trust in Carolina Whistleblower Attorneys. We have helped the government recover millions of dollars, with a large chunk of that awarded to the whistleblowers we’ve represented.1

In one nursing home fraud case, then-US attorney Bill Nettles – who now leads our firm – reached a settlement with one of the country’s largest drug suppliers to nursing homes, PharMerica Corp., to resolve a whistleblower lawsuit. The corporation allegedly received kickbacks in exchange for forcing nursing home residents to switch to a specific drug, even when it didn’t meet their medical needs. After serving the public for many years as a government attorney and holding many fraudsters accountable, Bill started our firm to try to help private citizens get rewarded for doing the right thing.

Worried what happens after you blow the whistle? Our You-First policy explains what you can expect during the whistleblower process and how we will fight to protect your confidentiality as much as possible while you perform this public service. And we will use the full power of the law to try to prevent and fight back against any retaliation by your employer.

If you believe your nursing home is involved with Medicare, Medicaid, or TRICARE fraud, please call Carolina Whistleblower Attorneys at 1-888-292-8852 or send us a message here.

Awards we’ve won

For standards of inclusion for awards listed, visit bestlawyers.com, thenationaltriallawyers.org, superlawyers.com, farrin.com/business-nc-power-list, and millondollaradvocates.com. National Trial Lawyers Top 100 designation is for 2022. Regarding the Million Dollar Advocates Forum, we do not represent that similar results will be achieved in your case. Each case is different and must be evaluated separately. Firm award is for the Law Offices of James Scott Farrin. Attorney awards are for attorneys with the Law Offices of James Scott Farrin.

Contact the Carolina
Whistleblower Attorneys

If you’re wondering if it’s a good idea to speak with a whistleblower lawyer about what you know, let us set the record straight.

  • Corporate ethics hotlines can be risky and may lead to termination. If you’ve already done this, call us immediately.
  • Your coworkers could be aware of the fraud – or complicit in it – and you should not talk to them about it.
  • The first claim to be filed under the False Claims Act can proceed – if you’re not first, you’re at a serious disadvantage and may get nothing (another reason not to speak to your coworkers about it).
  • A confidential discussion costs you a few minutes, but could save you time, stress, and money.

1-888-292-8852

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Disclaimer: Submission of any information to CarolinaWhistleblower.com does not constitute an attorney-client relationship. We have attorneys licensed to practice law in North and South Carolina.

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