Now that was one tough week

John O'Connor
John O'Connor

Most long-term care facilities would probably like to forget about last week. That's because two figurative bombshells exploded. Their collective impact: Operators can expect closer monitoring, unfavorable lawsuits and more ways to end up in prison.

Second things first: On Thursday, the Supreme Court handed down an unfavorable False Claims Act ruling. In voting 8-0 to uphold a controversial legal theory, the court essentially opened the door for many more of these lawsuits going forward.

The case involved a Massachusetts mental health clinic whose Medicaid reimbursement claims were deemed false. Provider organizations and other businesses were hopeful the justices would eliminate or at least rein in lawsuits based on the allegation that contracting organizations had not met certain legal or regulatory requirements not specifically outlined in a government contract. Alas, that was not meant to be.

The ruling came just a few days after the Centers for Medicare & Medicaid Services announced plans to unveil yet another program that targets Medicare/Medicaid fraud and abuse. As part of the stepped-up effort, CMS also plans to start using a predictive analytics program that can stop questionable payments before they are made.

Skilled care operators could be forgiven if they feel like they are wearing a bull's-eye when it comes to payment oversight. And is it just me, or does it seem that the monitoring is being stepped up as never before? It's almost as if CMS views skilled care as a criminal enterprise until proven otherwise.

Of course, when audits regularly find massive upcoding and outright fraud, it's hard to blame the regulators for being a bit suspicious. And it's not like the bad actors aren't regularly being cited in newspapers and elsewhere for playing fast and loose with the rules.

I truly believe that most skilled care operators are trying to run their facilities in a professional and ethical manner. But there are two ugly truths about this field that nobody likes to talk about in polite company. One is that there are a few — and maybe more than a few — rascals out there who are grabbing every possible dollar they can by any means necessary. The second is that the good operators are doing nothing to stop them.

If this field won't hold its bad apples accountable, we shouldn't be surprised when strict and even draconian rules are put in place by those who write the regulations and pay the bills.

Nor should be we terribly surprised if we continue to see more weeks that look that look a lot like last week.

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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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