We have been accused of admitting residents who do not really need skilled care. As a non-clinician in charge of making sure we are not defrauding the government, how can I/we make sure certain staff are not getting overzealous in a quest to keep census high?

Your question raises serious concerns and potential liabilities for billing Medicare or Medicaid for residents who do not qualify for government-funded services because they do not need skilled care. First, the government funders could deny the request for payments to non-skilled level residents. These same government funders could audit the licensed provider to seek a refund of any past payments that were fraudulent.

These government funders can seek recoupment of all fraudulent payments within the statute of limitations. This could be a huge recoupment, or they could put a block on future payments for services for qualified residents. 

If the government thought the fraudulent activity was intentional, they may seek to decertify future involvement of the licensed facility in the various government funded programs. The licensing agency also may seek delicensing of the nursing facility. That fact that certain staff were “overzealous “ will not defeat these liabilities.  

There are a few steps you should take to erase or minimize these exposures. The nursing home should establish admission procedures that prohibit the admission of persons who do not need skilled care. 

All staff should be notified of these procedures and their obligations to follow the procedures.  

Further, all staff should be informed that if they do not abide by the admission procedures, they are subject to discipline, up to and including discharge.