Discrimination in nursing
homes has economic roots. Many nursing homes may prefer to take private paying patients
because the private rate is higher than the medical assistance (Medicaid) rate. Medicaid
discrimination occurs most frequently upon admission, or upon a need to convert from
private payment to Medicaid status. This article includes detailed regulatory language
that describes the prohibitions concerning Medicaid discrimination, as well as information
for families of Medicaid recipients that will help them spot fraud and abuse.One sign of potential discrimination is the response given to a prospective
resident receiving Medicaid or friend of the prospective resident who contacts a nursing
home to see if a bed is available and is told that the nursing home has a
"quota" on "Medicaid beds," or only agrees to accept the resident if
he/she agrees to pay privately for a certain time period prior to applying for or
receiving Medicaid.
Another sign of discrimination occurs when a private pay resident
indicates to the nursing home an intention or desire to apply for Medicaid (when the
facility participates in the Medicaid program) and the nursing home informs the resident
that such application will result in his/her transfer to another nursing home.
Federal law requires that no provider shall solicit, charge, receive
or accept any money, gift or other consideration from a recipient, or from any other
person, for any item of medical service for which payment is available under the Medicaid
program, in addition to, in lieu of, or an advance or deposit against the amounts paid or
payable by the Department of Health and Human Services for such item, except to the extent
that the regulations specifically require or permit contribution or supplementation by the
recipient or by health insurers.
Federal law makes it a felony for a provider to "knowingly and
willfully" (1) charge, for any service provided to a patient under the state Medicaid
plan – money or other consideration at a rate in excess of the rates established by
the state, or (2) solicit, accept or receive (except for approved charges under a state
plan), any gift, money, donation or other consideration (other than a charitable,
religious or philanthropic contribution from an organization or from a person unrelated to
a patient (a) as a precondition of admitting a patient. . .to a skilled nursing home or
intermediate care facility, or (b) as a requirement for the patient’s confined stay
in such a facility. . . where the cost of services to the patient is paid in part or in
full under the state plan.
Therefore, it is a discriminatory practice to move or transfer a
nursing home resident from one setting to another (i.e., from a private or semi-private
room to a ward) solely because that person’s source of payment has changed to
Medicaid from private pay. It is also a discriminatory practice for a nursing home to
solicit or accept money to make up the difference between the private pay rate and the
Medicaid rate.
Some conditions which might indicate Medicaid discrimination are:
- Nursing home refuses to accept an admission application from a
Medicaid recipient or family member, or refuses to place the applicants name on a waiting
list;
- Nursing home informs the applicant that it is not presently accepting
any more Medicaid patients, or that its Medicaid quota has been met, or all of its
Medicaid beds are full;
- Nursing home suggests that admission may be expected or facilitated
if the patient could be a private pay patient for a period of time;
- Nursing home suggests that the Medicaid recipient must sell his/her
home and use the proceeds for nursing home care before getting Medicaid benefits;
- Nursing home informs the private paying family that when private pay
funds are exhausted, the resident will be transferred to a different room; or
- Nursing home says that it has no beds only after finding out that the
patient is a Medicaid recipient.
Identifying and Preventing Medicaid Fraud and
Schemes
- Billing for Services Not Rendered: A provider bills for services not
rendered, x-rays not taken; a nursing home continues to bill for services for a patient
who has died or been transferred;
- Double-Billing: A provider bills both the Medicaid program and a
private insurance company (or recipient) for treatment; or two providers request payment
on the same recipient for the same procedure on the same date;
- Substitution of Generic Drugs: A pharmacy bills Medicaid for a brand
name prescription but supplies a low-cost generic drug to the recipient;
- Unnecessary Services: A doctor performs numerous tests which are
medically unnecessary; equipment or medical supplies are provided and billed for that are
not medically necessary;
- Upcoding: Medicaid is billed for more expensive procedures than those
that are performed; individual therapy codes are billed for group therapy sessions;
- Kickbacks: A provider (e.g., nursing home owner) requires another
provider (e.g., lab, ambulance company, pharmacy) to pay a portion of the money the second
provider receives for rendering services to the first provider’s Medicaid patients;
- False Cost Reports: A nursing home owner includes inappropriate
expense for Medicaid reimbursement.
What to do if you suspect Medicaid discrimination or fraud:
- Contact your local Long Term Care Ombudsman
- Contact your local Medicaid agency
- Contact your state Attorney General’s Medicaid Fraud Control
Unit
