1. NURSING HOME FRAUD SCHEMES: FORENSIC ACCOUNTING LESSONS FROM LITIGATION.
- Author
-
Blythe, Stephen and Goodpasture, James
- Subjects
NURSING care facilities ,FRAUD ,IDENTITY theft ,FORENSIC accounting ,COMPLAINTS against nursing care facilities - Abstract
The researchers analyzed forty of the most significant appellate cases of nursing home fraud that were decided by the eleven circuits of the United States Court of Appeals during the past forty years. A study of those cases led to these conclusions: (1) the crimes for which nursing home fraudsters are commonly prosecuted include healthcare fraud, conspiracy to commit healthcare fraud, making false statements relating to healthcare matters, payment of kickbacks, and identity theft; (2) nursing home fraudsters included nursing home owners, managers, suppliers, regulators, medical personnel and other employees; (3) types of nursing home fraud include provision of egregiously poor service, overbilling for services to actual patients, billing for services to non-existent patients, payment of kickbacks to patients or to recruiters of patients, selling and charging for unnecessary medical equipment and supplies, or purchasing such equipment from a related party supplier at an inflated price; (4) nursing home fraud convicts received lengthy prison sentences ranging from a few years to more than 20 years, depending on the amount of money defrauded, and were required to reimburse the victim for the full amount of the fraud; (5) if a nursing home's accounting records are inadequate or if it refuses to provide its accounting records, its auditor is allowed to use statistical extrapolation to estimate the amount of Medicare reimbursement a nursing home is legally entitled to; (6) a nursing home may not refuse to produce its Medicare provider cost reports merely because that could result in disclosure of its trade secrets; (7) a successor nursing home purchaser may be liable for payment of the seller's Medicare penalties pertaining to fraud; 8) a nursing home which successfully disagrees in good faith with the government's calculation of the amount of Medicare reimbursement it is entitled to may be reimbursed for its accounting and legal expenses incurred in an administrative process or court action; and (9) the statute of limitations for filing a lawsuit for Medicare reimbursement to a nursing home is within two years after the date the cost of the services becomes determinable. [ABSTRACT FROM AUTHOR]
- Published
- 2018