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LTACH Fraud

Each patient discharged from a long-term acute care hospital is assigned to a distinct long-term care diagnosis-related group, referred to as LTACH-PPS. Payment is a pre-determined fixed amount applicable to the reported LTACH-DRG, which are based on the patient’s reported condition (and adjusted for area wage differences).

Long-Term Care Fraud

LTACH PPS includes payment for all inpatient operating and capital costs of furnishing covered services (including routine and ancillary services). LTACH-PPS also includes special payment policies that adjust the payments for some patients based on the patient’s length of stay, the facility’s costs, whether the patient was discharged and re-admitted, and other factors (such as short-stay cases and high cost outlier cases).

In order to remain categorized as a LTACH, a hospital must have an average inpatient length of stay for Medicare patients (including both Medicare covered and non-covered days) of greater than 25 days. LTACHs that fail to exceed an average length of stay of greater than 25 days for Medicare patients during any cost reporting period are paid under the general acute care hospital DRG-based reimbursement.

In addition, LTACH’s are paid extra for certain pass-through costs, such as bad debts, direct medical education, and blood clotting factors. Unlike the prospective payment system for inpatient acute care hospitals, LTACH PPS makes no adjustments for geographic reclassification, disproportionate share of low-income patients, rural location, or indirect medical education.

Violations of the False Claims Act often include the widespread and systematic upcoding of DRGs, manipulating LOSs, and falsifying pass-through costs.

REAL PEOPLE making real change Healthcare Fraud Wins

Joe Strom

Johnson & Johnson
$184 Million

Joe Strom contacted us in 2005. We were very grateful that he did. We immediately formed an all-star legal team and a process to stop a very harmful pharmaceutical marketing strategy. It was this process we set into motion that ultimately returned hundreds of millions of dollars to the U.S. Treasury, and a portion of that, very well-deserved, into Joe’s bank account.

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Bruce A. Moilan Sr.

$27 Million

Bruce Moilan was a seasoned hospital systems expert by the time he contacted our Firm. At the time he decided to file his qui tam lawsuit, he was employed by South Texas Health System as a System Director for Materials Management. In this position, he oversaw $24 million in annual purchases of supplies and equipment and helped determine budget, reduction and cost analysis throughout the contract bidding and negotiations process. His job was to insure proper implementation for purchasing, receiving and management of inventory, for McAllen Hospitals, L.P.

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“I collaborated with Nolan, Auerbach and White on a broad variety of cases where whistleblowers stepped forward to disclose tactics employed by large companies to influence physicians' medical decision-making in patient care. They and their medical consultants, have consistently leveraged biomedical research and best medical evidence to advance patient safety, optimize clinical outcomes, and control precious resource utilization.”

— Fred Polsky M.D.,, Former Medical Director, CMS Zone 7 Integrity Contractor

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