Pennsylvania Retirement Community Settles With Government Amid Medicare Fraud Allegations

According to a press release by the Department of Justice released on April 15, 2015, Pittsburgh’s Asbury Health Center has agreed to pay $1,331,837.96 to settle claims it did not follow proper protocol with regard to post-hospital skilled nursing services.

Under applicable Medicare Part A rules, a patient may be eligible for post-hospital skilled nursing services if, in the opinion of the facility’s attending physician or a physician on staff at the skilled nursing facility, the patient will require ongoing daily nursing care as a result of the medical condition or procedure previously treated at the hospital. In order for the patient to qualify for Medicare Part A coverage for post-hospital skilled nursing services, the physician must submit an initial certification of such eligibility. These certifications must be obtained immediately upon admission. Likewise, if the patient is in need of skilled nursing beyond 14 days, a recertification must be submitted as soon as possible, as well as every 30 days thereafter.

Allegedly, these particular guidelines were violated by Asbury Health Center, resulting in a number of Medicare reimbursements on behalf of patients with improper paperwork to document their need for skilled nursing services.

Details of the case against Asbury Health Center

Unlike the majority of False Claims Act cases, which are commenced by courageous and forthcoming whistleblowers, the case against Asbury Medical Center occurred as a result of its own self-disclosure of the problem. According to the Department of Justice, Asbury was in the routine practice of admitting Medicare Part A enrollees for post-hospital skilled nursing services, despite a consistent failure to certify those patients as eligible upon admission, at the 14-day deadline, and at the 30-day deadline.

On its own volition, Asbury retained an independent compliance auditor to review its records and paperwork for adherence to Medicare rules. It was upon the conclusion of this audit that the center allegedly first realized it was admitting patients without proper documentation, and the matter was disclosed to the Department of Justice.

In a statement to the media, Asbury’s spokesperson reiterated that the matter was in no way caused by “misfeasance,” but was rather a technical glitch in its paperwork and documentation systems. Nonetheless, prosecutors for the DOJ assert that Asbury could have faced False Claims Act liability in the event a settlement was not reached.

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