Hopefully all of our nursing home clients know by now that CMS and the OIG have psychotropic drug use by nursing home residents on their radar.  A recent case filed by the Department of Justice (DOJ)  raises another concern that nursing homes may not have considered.  A Chicago psychiatrist was charged with violating the False Claims Act by allegedly submitting at least:

  • 140,000 false claims to Medicare and Medicaid for antipsychotic medications he prescribed to thousands of mentally ill patients in Illinois nursing homes; and
  • 50,000 false claims for falsely stating he provided “pharmacological management” for his patients at more than 30 nursing homes and long term care facilities.

The charges stem from Dr. Reinstein’s alleged relationship with several drug manufacturers of clozapine, which the DOJ asserts ”is a rarely-used medication that has serious potential side effects and is generally considered a drug of last resort, particularly for elderly patients.”  According to the DOJ, clozapine is generally prescribed for only 4 percent of persons with schizophrenia while more than 50 percent of Dr. Reinstein’s patients were prescribed the medication.  It is alleged that at one nursing home, 75 percent of the 400 residents were on the medication.  The OIG is seeking a civil penalty of $5,500 to $11,000 for each alleged false claim.

Our insight.  Your advantage.  With the alphabet soup of auditors (RACs, ZPICs, MACs) looking at nursing home records, nursing homes do not need the DOJ or the OIG also reviewing them for whatever reason.  Even if the nursing home is not the target or the subject of an investigation for which a document subpoena is issued, once the records are in the government’s hands, who knows who else will be looking at them or what else in the records might be of interest.  If a nursing home finds that a physician is prescribing a medication or treatment that is out of the norm, it is to the home’s advantage to look into it further.  There may be legitimate medical reasons for the prescribing, but it is better for the nursing home to be proactive rather than reactive.  A well-designed and functioning corporate compliance plan should include auditing tools to alert staff to possible concerns.