September 6, 2019 - Posts

PDPM is Coming to the World of Skilled Nursing. Is a New Wave of Medicare Fraud Coming With It?

As physical, occupational, and speech language therapists around the country already know, RUG Rates will soon be a thing of the past.  Starting October 1, 2019, the Centers for Medicare and Medicaid Services (“CMS”) is moving to a new model of reimbursement for skilled nursing facilities (“SNFs”) and their Medicare Part A patients.


Rather than linking payment to minutes of therapy, as the RUG Rate system did, the new “Patient Driven Payment Model” or PDPM , aims to align reimbursement more closely to actual patient needs and resource utilization.


The RUG system was deeply flawed, and this law firm has been proud to represent therapists who brought to light massive schemes to defraud Medicare by providing and billing for unnecessary therapy minutes.


But no billing system is perfect, and some therapists are already raising concerns about their SNFs responding to PDPM by adopting new billing schemes in place of their old RUG Rate schemes.  Specific concerns include providing Part A patients with too little therapy, misclassifying Part A patients under the new PDPM classification system to obtain higher per diem rates, and providing unnecessary therapy to Part B patients in order to make up for lost revenue.


If you work in a SNF and believe that your company is either defrauding or preparing to defraud Medicare under the new PDPM system, send us a message or give us a call. Email our partner, Jerry Martin, at He will gladly answer your questions on a confidential basis.


While our office is located in Nashville, Tennessee, we handle cases all across the country. We represent health care workers in wage and overtime claims and whistleblower claims for fraudulently billing Medicare and Medicaid programs.

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