To build on what is becoming a focused blog series, starting with our article in the June 2011 issue of Long-Term Living and last month’s blog on quality of care corporate integrity agreements, this installment focuses on the U.S. government’s recent quality of care False Claims Act (FCA) lawsuit against a Kentucky nursing home, Villaspring Health Care Center of Erlanger. Depending on the outcome, this case could help determine the course of future FCA quality of care cases.
The lawsuit accuses Villaspring of charging Medicare and Medicaid for care that was “either non-existent or so inadequate as to be worthless.” The government also named as defendants an alleged “parent” company for the nursing home and its CEO, who is allegedly the “majority owner.”
As alleged in the complaint, the government defines “worthless services” as services that “were not provided, were deficient, inadequate, substandard, and did not promote the maintenance or enhancement of the quality of life of the residents of Villaspring, and were of a quality that failed to meet professionally recognized standards of health care.”
The complaint alleges that the facility received almost $16 million from the Medicare and Medicaid programs from 2004 through 2008; however, the complaint identifies just six residents whose care was allegedly deficient. For those six residents, the facility received $108,802.32 in total Medicare and Medicaid payments. Tellingly, the complaint does not specify whether the government contends that all of those payments were for “worthless services,” which as we have discussed in our prior submissions, is a major hurdle for the government in quality of care cases. Even if the full amount of the payments were trebled under the FCA, the total damages as identified in the lawsuit at this time would only equal $326,406.96.
Yet, the real exposure for the facility may be in the government’s definition of a “claim,” whereby each problematic claim could result in a penalty under the FCA of between $5,500 and $11,000, which would be on top of the treble actual damages claimed by the government. But how are “claims” defined in a nursing home that bills on a prospective payment basis or under a daily rate? Liability under the FCA occurs when a person “knowingly presents, or causes to be presented, to an officer or employee of the United States Government … a false or fraudulent claim for payment or approval.”