The government is moving forward with allegations that one of the largest nursing home facilities in New York has received over $30 million in Medicare overpayments. A federal watchdog group uncovered the issue and reviews by the Office of the Inspector General (OIG) thus far appear to support the claims. The agency is pushing for repayment. The case provides an opportunity to discuss how these types of investigations are moving forward in the current climate.
#1: AI is allowing for large audits
Not surprisingly, federal watchdog groups and government agencies are making use of artificial intelligence (AI) software to help review large amounts of data to flag any potential violations. Although this can be efficient, anyone that has used AI knows there are nuances. It often fails to take other factors into account–factors that could explain what may look like an overpayment but was, in fact, within the bounds of the law.
#2: Agencies will review medical records
Facilities are understaffed, demands are high, and a need to move on to the next patient who needs care can cause physicians and other medical staff to take shortcuts when filling out paperwork. It is important to keep thorough, clear and organized medical records. In this case, inspectors for the OIG state they are reviewing medical records provided by the facility and have not found evidence to support the claims.
#3: Defenses are available
Even when investigators build an argument like the one noted above, defenses are available. In this case, the nursing home argues that they did not intentionally defraud the government but instead misapplied coding guidelines and that there were errors with the audit. The biggest error, according to representatives for the nursing home, involved a failure of the auditors to take into account waivers during the COVID-19 pandemic.
Facilities and medical practices can use this case as a reminder to conduct regular internal audits to check for compliance with Medicare billing rules. Know that agencies and watchdogs are checking for mistakes and will aggressively pursue any signs of overpayment. Those who receive notification of an impending audit are wise to take the matter seriously and begin preparations to appeal the agency’s determination.
Attorney John Rivas is responsible for this communication.
