A Medicare whistleblower stands to collect millions of dollars for turning in her employer for alleged fraud.

Tammie Taylor reported fraud at Life Care Centers of America, a large corporate owner of skilled nursing facilities. Federal regulators investigated and ultimately fined Life Care $145 million.

Taylor, a Miami resident, and fellow Medicare whistleblower Glenda Martin from Tennessee will share $29 million. A certain percentage of that amount will go to their respective legal teams, who worked on the case for eight years.

In addition to the fine, Life Care also is on administrative probation for five years because of the violations. An independent organization will conduct an annual review to assess the medical necessity and appropriateness of therapies billed to Medicare.

Medicare Whistleblower’s Journey

Taylor worked at Life Care’s Inverrary, Florida facility for seven months. During that time, she was told to provide all patients with identical, maximum regimens, whether or not the services were necessary.

After questioning the possible harmful effects that “maximum therapy” could have on some patients, Taylor was fired.

Nursing facilities are reimbursed by Medicare at a daily rate that is tied to the skilled therapy and nursing needs of patients who qualify. When a patient needs the most highly skilled therapy and nursing care, the facility is reimbursed at a higher rate.

The pinnacle reimbursement rate is for “Ultra High” patients who need a minimum of 720 minutes of skilled therapy from two therapy disciplines, such as physical therapy, occupational therapy or speech therapy. At least one of the prescribed therapies must be provided five days a week.

According to the Medicare whistleblowers and according to the government’s complaint, “Life Care instituted corporate-wide policies and practices designed to place many beneficiaries in the Ultra High reimbursement level irrespective of the clinical needs of the patients, resulting in the provision of unreasonable and unnecessary therapy to many beneficiaries.”

The Department of Justice said Life Care had some of its 220 facilities across the United States “submit false claims to Medicare and Tricare for rehabilitation therapy services that were not reasonable, necessary and/or skilled.”

“Billing federal healthcare programs for medically unnecessary rehabilitation services not only undermines the viability of those programs, it exploits our most vulnerable citizens,” said U.S. Attorney Nancy Stallard Harr for the Eastern District of Tennessee. “We are committed to working with our federal partners to protect both.”

“The resolution announced today demonstrates the commitment of the U.S. Attorney’s Office to aggressively pursue providers who utilize fraudulent practices to knowingly put their own financial self-interest over a duty to patients,” said U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida.

“It is imperative that providers make healthcare decisions based upon a patient’s need for services rather than a self-serving desire to maximize financial profit.  Our office will continue to investigate fraud allegations, in order to ensure that providers do not compromise the integrity of our public health care programs.”

The Medicare Whistleblower Lawsuits are United States ex rel. Taylor v. Life Care Centers of America, Inc., Case No. 1:12-cv-64 (E.D. Tenn) and United States ex rel. Martin v. Life Care Centers of America, Inc., No. 1:08-cv-251 (E.D. Tenn).