Damian Williams, the United States Attorney for the Southern District of New York, and Scott J. Lampert, Special Agent-in-Charge of the New York Regional Office of the U.S. Department of Health and Human Services, Office of the Inspector General (“HHS-OIG”), announced today that the United States has filed and settled a civil healthcare fraud lawsuit against TCPRNC, LLC d/b/a PLAZA REHAB AND NURSING CENTER (“PLAZA REHAB CENTER”) and CITADEL CONSULTING GROUP LLC d/b/a CITADEL CARE CENTERS LLC (“CITADEL”). The lawsuit alleges that PLAZA REHAB CENTER, acting at the direction of CITADEL, fraudulently switched the type of Medicare coverage in which elderly residents were enrolled in order to maximize the Medicare payments that PLAZA REHAB CENTER would receive. As alleged in the Government’s complaint, the residents and their families often did not request, consent to, or know about the change to their healthcare coverage, which had the potential to impact their out-of-pocket payments, the scope of the services and care covered, and their drug coverage plan.
U.S. Attorney Damian Williams said: “Skilled nursing facility residents have the right to choose their own healthcare insurance coverage. Plaza Rehab Center frequently changed the insurance of its residents without their consent or knowledge, and without explaining how the change could impact their out-of-pocket costs and the scope of their healthcare coverage. When facilities unlawfully take advantage of elderly residents in order to maximize their revenue from federal healthcare programs, this Office will hold them accountable.”
HHS-OIG Special Agent-in-Charge Scott J. Lampert said: “HHS-OIG is committed to safeguarding Medicare and its beneficiaries from fraud. Those who exploit federal health care programs for financial gain and violate the trust of beneficiaries must be held accountable for their actions.”
Under the settlement, which was approved on June 27, 2022, by U.S. District Judge George B. Daniels, PLAZA REHAB CENTER and CITADEL agreed to pay a total of $7.85 million and made extensive factual admissions regarding their conduct. Specifically, PLAZA REHAB CENTER and CITADEL admitted that their staff often did not obtain the consent of the resident or their authorized representatives prior to disenrolling the resident from their Medicare Advantage Plan. In addition, as part of the settlement, CITADEL agreed to take steps to ensure that all skilled nursing facilities that are Citadel Care Centers comply with applicable guidance on Medicare health plan disenrollments and enrollments. PLAZA REHAB CENTER and CITADEL also entered into a Corporate Integrity Agreement with HHS-OIG, which requires that they maintain a compliance program designed to foster adherence to federal health care program requirements and thereby protect the programs.
Medicare beneficiaries may enroll in the original parts of Medicare, known as Original Medicare, or in Medicare Advantage Plans, which are administered by private companies that contract with the government. Original Medicare and Medicare Advantage Plans differ in how healthcare providers, including skilled nursing facilities, seek and receive reimbursement. Under Original Medicare, the Centers for Medicare & Medicaid Services (“CMS”) directly reimburses providers, like skilled nursing facilities, on a fee-for-service basis. In contrast, when furnishing medical services to a Medicare beneficiary enrolled in a Medicare Advantage Plan, the provider submits claims to the Medicare Advantage Organization (“MAO”) that operates the Medicare Advantage Plan, which in turn pays the provider an agreed-upon amount. CMS pays MAOs a fixed, capitated amount each month for providing coverage for Medicare beneficiaries enrolled in the Medicare Advantage Plan. CMS advises individuals to consider various factors in deciding between a Medicare Advantage Plan and Original Medicare, such as differences in out-of-pocket costs and doctor choice.
As alleged in the Complaint filed in Manhattan federal court:
It is well known within the skilled nursing facility industry that it is typically more profitable to admit residents who are enrolled in Original Medicare than residents enrolled in Medicare Advantage Plans. From September 2016 to February 2019, CITADEL exerted pressure on PLAZA REHAB CENTER staff to increase the number of residents enrolled in Original Medicare in order to increase Medicare reimbursements. PLAZA REHAB CENTER staff disenrolled many residents from their self-selected Medicare Advantage Plans and enrolled them in Original Medicare without obtaining the consent of the residents or their authorized representatives.
PLAZA REHAB CENTER staff were supposed to ensure that residents (or their authorized representatives) signed “disenrollment forms” prior to effectuating any disenrollment of the resident from their Medicare Advantage Plan. However, in many instances, PLAZA REHAB CENTER staff disenrolled residents from their Medicare Advantage Plan and enrolled them in Original Medicare without obtaining a signed disenrollment form reflecting the resident’s consent. Indeed, PLAZA REHAB CENTER employees effectuated numerous disenrollments without ever speaking to the resident or their authorized representative or explaining the consequences of switching to Original Medicare. In addition, in other instances, PLAZA REHAB CENTER staff discussed a disenrollment with the resident and purportedly obtained the resident’s consent, but the resident did not have the capacity to provide consent because of their health condition.
In the settlement agreement, PLAZA REHAB CENTER and CITADEL admit, acknowledge, and accept responsibility for the following conduct:
- PLAZA REHAB CENTER staff, at the direction and under pressure from a CITADEL manager responsible for the new admission practices, changed PLAZA REHAB CENTER residents’ insurance from Medicare Advantage Plans to Original Medicare after such residents’ admission to PLAZA REHAB CENTER. Among other things, CITADEL set a monthly disenrollment quota for PLAZA REHAB CENTER and identified potential candidates for disenrollment. PLAZA REHAB CENTER earned greater revenues for residents if such residents were enrolled in Original Medicare, as compared to Medicare Advantage Plans.
- PLAZA REHAB CENTER staff often did not obtain the consent of the resident or their authorized legal representatives prior to disenrolling the resident from their Medicare Advantage Plan and enrolling them in Original Medicare.
- In approximately 19 instances, PLAZA REHAB CENTER staff purportedly obtained the residents’ consent before disenrolling them from their Medicare Advantage Plan, but, according to these residents’ mental status assessments, they did not have the capacity to provide consent because of their health condition. PLAZA REHAB CENTER regularly failed to consider the results of these mental health assessments and did not evaluate the capacity of residents to consent to the insurance change.
- PLAZA REHAB CENTER staff effectuated these changes in a resident’s coverage by logging on to the Medicare.gov website using the resident’s personal information. PLAZA REHAB CENTER staff would use this website to disenroll the resident from their self-selected Medicare prescription drug plan, which resulted in the resident automatically being disenrolled from their self-selected Medicare Advantage Plan and being enrolled into Original Medicare. In some instances, when completing the information online to effectuate the disenrollment, PLAZA REHAB CENTER staff misrepresented that they were either: (i) the person listed on the enrollment form; (ii) a person helping the person listed on the enrollment form in completing the form; or (iii) a person authorized to act on behalf of the individual on the enrollment form under the laws of the State where the individual resided.
- PLAZA REHAB CENTER and CITADEL often did not offer Plaza Rehab Center residents assistance in re-enrolling them in a Medicare Advantage Plan upon discharge from the Plaza Rehab Center facility.
- As a result of the conduct described above, the Government made payments under Original Medicare to PLAZA REHAB CENTER for residents who were improperly enrolled in Original Medicare without their consent. PLAZA REHAB CENTER was not entitled to these payments.
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In connection with the filing of the lawsuit and settlement, the Government joined a private whistleblower lawsuit that had previously been filed under seal pursuant to the False Claims Act.
Mr. Williams thanked HHS-OIG for its investigative efforts and assistance with the case.
This case is being handled by the Office’s Civil Frauds Unit. Assistant United States Attorney Charles S. Jacob is in charge of the case.