Knowledge base

Back to Knowledge Base

Skilled Nursing Facility Payment Fraud

Under the PPS system for SNF’s, each beneficiary is designated to over 40 resource utilization groups (RUGs), each containing patients with similar service needs that are expected to require similar amounts of resources. The daily rate for each RUG is calculated using the sum of three components: 1) a fixed amount for routine services (such as room and board, linens, and administrative services); 2) a variable amount reflecting the intensity of nursing care patients are expected to require; and 3) a variable amount for the expected intensity of therapy services. Much like the other PPS’s, the RUG rates are computed separately for urban and rural areas and a portion of the total rate is adjusted to reflect labor market conditions in each SNF’s location. Qui Tam lawsuits often arise from upcoded RUG rates. Questions to ask include, are the rehabilitation and infusion therapy services provided to Medicare beneficiaries in skilled nursing facilities medically necessary, adequately supported, and actually provided as ordered? What is the extent and nature of consecutive Medicare hospital inpatient stays for its patients in general? Is the SNF billing for services on the day of discharge? Is there a failure to submit no-pay bills (which could contribute to inappropriate calculations of Medicare SNF eligible benefit periods)?

Contact Us

Contact Us

The more detailed the response, the more likely it is that we will be able to evaluate and determine if your potential False Claims Act case falls within our case requirements. If it does, WE WILL RESPOND TO YOU WITHIN 24 HOURS. (Names of potential defendants are not necessary at this point, should you feel more comfortable omitting them.) By law, all communications to us are 100% confidential.

Please enable JavaScript in your browser to complete this form.
No. of Employees at the Company?


Please read the following statement and then click “Send Form”:

Any response to your e-mail will be solely to communicate about our possible representation of you under the qui tam provisions of the False Claims Act. All e-mails submitted to us, whether we take your case or not, are 100% confidential. If we do not respond to your e-mail, then you have communicated information which we cannot address because it appears to fall outside of the False Claims Act or our case requirements.