| “Improper coding and upcoding” |
Non-reduction for patients under long-term care insurance exceeding standard claims periods |
Claiming reimbursement for a service or procedure at a higher level than that provided. |
“For eligible patients who are insured under long-term care insurance and received rehabilitation exceeding the standard number of days, rehabilitation fees were billed at the standard rate, instead of at the lower rate required.” |
5 |
| “Falsifying documents” |
Billing for rehabilitation fees based on the false onset of new diseases |
Certificates were falsified to demonstrate the medical necessity of a particular procedure to justify payment. |
“For patients who experienced a single onset of a disease or condition, rehabilitation fees were repeatedly billed―even after the standard number of days―by falsely documenting a new onset of a disease or condition in the claims’ remarks column. This allowed for the continuous billing of a rehabilitation fee that is otherwise limited to the standard number of days.” |
2 |
| “Providing unnecessary care and maximizing care.” |
Billing exceeding standard calculation days for patients unlikely to improve with continued treatment |
Provision of medically unnecessary services, or the delivery of care in a greater volume than required for a patient’s treatment. |
“Rehabilitation fees were billed for a duration exceeding the standard number of days, even when the patients did not meet the established eligibility criteria, such as those for whom continued treatment was expected to result in an improvement of their condition.” |
2 |
| Billing for non-eligible patients |
Providing services to ineligible patients. |
“Rehabilitation fees were billed for patients who did not meet the eligibility criteria.” |
1 |
