Is this nursing home fraud?

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It turns out my uncle had to go to the hospital a few times since he's been in the nursing home resulting in quite a few days away. They had held his bed on each of these times. This was all during the time frame we were waiting for Medicaid approval. We finally got his approval and this fell during the approved start date 1- Would this be anything that Medicaid would cover? I believe I read for the state of New York they cover 10 or 14 days in a year? and he had to have been there 30 days prior to first leave. 2- This is more the issue - We were served with a bill from the nursing home for the bed holds. This came as a shock to us, as we hadn't know we were being charged for this. I asked for documentation of where it was noted about this and the form(s) that was provided to us are forged signatures. His power of attorney (His sister) did not sign these documentations and they are very blatantly forged. I'm not even sure where to turn to from here or what to do next as this is the first time having to deal with anything like this. If someone could provide some views?

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You have some serious issues to address arising from a potential forgery. I'm undecided about raising that issue to the facility, but would err on the side of caution until you have more information. And I think there actually might be an explanation, but you'll need to approach the facility's admins cautiously w/o inference of blame if you want to get more information.

I think some questions could be helpful if we have answers, and I want to emphasize that I'm not challenging your conclusion, but it is a serious conclusion and will have to be verified and documented if any action is to be taken.

Most critically:

(a) Who chose this facility originally, and was it on recommendation of a discharge planner of a hospital, or was it selected by a family member? who worked with or negotiated with the facility to get him admitted? I.e., which family member? A friend?

(b) When did he enter this facility, who accompanied him, and was anyone asked to sign the admission papers? Are they signed as of the date of admission?

(c) When did the family receive a copy of the admission papers?

This isn't a criticism, but I'm just wondering how long ago the admission took place, whether anyone from the family had copies and if anyone reviewed them. I think this is important in determining when, if it is fraud, it actually took place.

(d) Who worked with the facility to get Medicaid on board?

(e) Whose signatures were allegedly forged? If you can, recreate the timeline, i.e., the individual(s) whose signatures appear to be forged and the dates of visit. These should coincide. If they don't, you may have support for the fraud charges.

(f) How is it "blatantly" determined that the signatures were forged? Is it possible your uncle actually signed himself but that his signature is not representative because of his medical condition at the time? This would NOT be unusual.

(g) Does this apply to all the forms? Typically some forms are witnessed. Who witnessed the signatures?

I reiterate that I am not criticizing anyone for actions or failure of actions. These are in my experience always unsettling times, and it's easy for confusion to result. I've had plenty of "OMG - I forgot to....") when going through hospitalizations or rehab admissions.

But I think any law enforcement officer investigating potential fraud or an attorney considering other action would ask similar questions.

I'm sorry to learn that your family is in this situation; it's frustrating and unsettling enough when a loved one is ill but made much more so by concerns that someone is committing fraud.
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When I entered a NH for rehab the paperwork I was given clearly stated that the fee for bed hold woud be $120 per day in NYS. I was readmitted to the hospital on day 4 and had no intention of returning to rehab. If I had wanted to go back to the same NH I would have had to take the first rehab bed availabe in the area. It could have been the same NH if they still had a bed but there was no guarantee without a bed hold. Medicare was paying for me
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So Medicaid R&B $ 160 day, right? Hope they accept that!

But I'm confused, so he entered Nh Dec., so now 10 months, right?
But has NOT done his required each mo of his income co-pay for 10 months.
He owes Dec - March SS, 4 months, right?
And he co-paid none of his pension, so owes 10 months pension too?
That's a lot of required copay $$$ the NH is owed.
If this is right, NH has been very very welcoming to your uncle to still have Him as a resident & do bed holds imho. Most places issue a 30 Day Notice (that they have to move out) at month 5 or 6.

I'm going to guess a couple of things.... I'd bet he had hospital admits within this 10 months that some of his stay at the NH was under the MediCARE post hospitalization rehab benefit. It's a totally different payment structure than LTC Medicare&Medicaid. Depending on his ICD-10 codes, he could possibly have more than 1 post hospitalization rehab mediCaRE paid benefit. It's unlikely but if he did, he's lucky. The billing statements from the NH will be lots of billed abc then days later billed xyz then abc totally credited then efg billed then 80% of efg credited. & it's on & on with this. The NH / hospital yo-yo's are a sea of paperwork. It will also get repeated in the statements that CMS mails out. It could account for some of the white outs. I'm not saying this to let the NH off the hook if there's fraud on signatures but more they do what they needed to get him back into a bed.

I'm surprised NH has waited till mo 10.
Was there someone else in the family that was his DPOA & they did his NH admissions & dealt with his hospital stay back in November. So you're coming in now & dealing with all this?

Also the 10k & 8k paid, what were these for? Are you expecting a provider or vendor to rebill to Medicaid and return payment $?
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Yes his rate is $160. Well he just got the approval for Medicaid last week and it's retro to Dec 1, 2016. The nursing home has been getting his SS since April, but we owe them the pension as of December. Problem is we paid two bills in January and February of around 10K and 8k that would of been covered by Medicaid and we would just need to provide is SS & Pension per his agreed income.

Further review - I've noticed that they've actually taken one form of the "Status of Bed Reservation Notification" where they indicate we asked to hold the bed and they actually took one and photo copied it and white'd out the dates to reflect another stint he did in the hospital. There are SO many signs that this is absolute fraud.

Even if on his admission documentation we are aware of the $400 rate, wouldn't this form and approval need to be clear that we agreed we wanted to hold the bed. Clearly this never happened and they made the documents themselves. Wouldn't they need consent to charge us?
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Try to google to find out just what your states Medicaid daily R&B rate is. Some states are low like $ 160 a day. But others - esp upper east coast states - much higher. Also I'd suggest you go in knowing what his "awards" letters state as to his income. As those $ amounts are what his required co- pay each mo to the NH is. Awards letters are the trifold letters that SS, and other retirements (civil service, pensions) send out like Nov or Dec that state to the penny what they will pay each month.p fir the incoming year. He has been paying his SOC (share of cost) to the NH each month less a smallish personal needs allowance, right? He needs to totally be current on his SOC before you start negotiating "away" fees imo.

In theory NH are supposed not to show favoritism for those with higher co pay. Yeah sure & I have waterfront on Louisiana marshland to sell you..... But they do. A lot of those on Medicaid if advanced elderly (in their 90's) have tiny SS income. Like $700 -800 a mo. My mom - in her 90's- had SS & civil service annuity (dad was a fed) & $1900 a mo. I could tell admissions & billing were very over the moon about her copay as they'd get $ 1840 a mo definitely (TX has $ 60 personal needs allowance) while they waiting her her to clear Medicaid Pending. 

Oh also if the N.h has been getting his income each mo, there a personal needs trust account at the NH getting the PNA $. He can use this funds to pay towards the "away" time. If dad is an easy resident for care, they could want to keep him & be glad to cut a deal with you. 

Good luck & let us know what you find out. We all learn from each other!
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Forged by whom? I wouldn't bring that up either if you can't prove it. Which family member was with her when she was admitted and why would the nursing home forge anyone's  signature? Why & how did that happen?
Nursing home fraud? Forgery?
This is alarming. 
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Thanks for the info. I am going to request the admissions paperwork from them to see about the away portion. I'm going to meet with them tomorrow to discuss, but I don't know if I should mention the forged signatures then and there and see if we can settle on the R&B rate which is less than half of what they were charging for the hold.
My issue is that we didn't acknowledge holding the room at a certain rate, so how can we be charged for it. The paper that has the consent on this was actually forged by the nursing home.

Yeah there were extended times he was in the hospital for around 10 days, but then there were days as little as 1 for observation.
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Also I'd like to add, the THV were pretty commonly done at my moms second NH. Like 8 or so families regularly in late Friday afternoon to pick up their spouse or elder (& their laundry!) and back mid afternoon Sunday.
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Each state determines the specific timeline under federal guidelines. So you need to check your states HHS websites
There will be 2 types of "aways"..... I had to deal with both for my mom at a NH in TX
- hospitalization, if they enter & have a real hospital stay, they are considered discharged from the NH as their now a hospital admission. If family want NH bed held, NH will need to charge a fee (& can be at private pay rate & not the lower Medicaid daily room & board rate) as they can't bill Medicaid for the room & board. That's what Gladimhere pointed out. BUT if in the hospital for "observation", the NH bed is still there & being paid by Medicaid as their not actually a hospital admission. My mom in her first NH and still Medicaid Pending & then on Medicaid had a couple of TIAs went to hospital under observation 2 nights both times and then back to NH still in same Medicaid status with no bed hold charge.
And then there's
-THV aka therapeutic home visits - These have a specific # of hours allowed away for bed to be held. I took mom for a family wedding on a Friday & was told to must have her back before dinner bell on Sunday. Cleared it with the DON & staff as I had to have them issue me moms RXs to take. NH are like public schools in that they have to do a daily census count to be reimbursed for sevices based on # of butts in seats /beds. If not back in time, they would have to let Medicaid know and she'd be "suspended" from LTC Medicaid. Just what that would involved I shudder to think about.....

I think you all are going to have to pay something to the facility if you want him to stay there. I'd try to get them to settle for the Medicaid reimbursement daily R&B rate as it will be the lowest price point.

Forgery issue, did whomever within family that took him day 1 at NH get a copy of all the admissions documents at the time of admission? What is in the stack of documents regarding "aways"? If not....... then you will have to request these in writing from the NH & NH can charge you a research fee & copy fee for them.
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Medicaid will not pay for two levels of care at the same time for the same person. I would report to Medicaid and the State Department of Social Services that licenses nursing homes.
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