The nation’s largest nursing home association is urging providers to properly educate staff on acceptable practices when it comes to discussing changes to residents’ healthcare coverage in order to avoid the same fate of a New York-based facility and operator that was ordered to pay nearly $8 million to settle fraud accusations.
The American Health Care Association/National Center for Assisted Living issued the warning to providers in a blog post Friday. It comes about a week after a $7.85 million settlement agreement reached between the federal government, Plaza Rehab and Nursing Center and its operator, Citadel Care Centers, in a civil healthcare fraud lawsuit.
Federal investigators accused Plaza staff of disenrolling many residents from their self-selected Medicare Advantage plans and enrolling them into Medicare without getting consent in order to maximize profits. Plaza and Citadel were both required to admit and accept responsibility for the violations as part of the $7.85 million settlement agreement.
AHCA on Friday said that federal health officials have made it clear that interfering with resident choice of healthcare coverage through disenrollment from Medicare Advantage plans is a violation of residents’ rights and federal law.
The latest guidance from the Centers for Medicare & Medicaid Services came in October 2021 that outlined policies and procedures providers should have in place when talking with residents about changes to their healthcare coverage.
“If a [long-term care] facility cannot provide documentation of a beneficiary’s request to change enrollment, this may suggest that the enrollment action was not initiated by the beneficiary or their legal representative and therefore was not legally valid,” CMS wrote in the 2021 memo. “Where an enrollment action is not legally valid, CMS may cancel the enrollment action and, if necessary and appropriate, reinstate the beneficiary’s coverage in the plan in which he or she was originally enrolled.”
In response, AHCA urged providers to develop internal MA Plan policies and procedures which incorporate the guidelines outlined in the 2021 memo.
“Educate staff on acceptable and unacceptable practices related to discussions and changes around resident healthcare coverage to avoid violations of these regulations,” AHCA said.
