How Medicare Lets Nursing Homes Get Away with Abuse - Mazow | McCullough, PC
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How Medicare Lets Nursing Homes Get Away with Abuse

Families trust nursing homes to provide a safe and secure environment for their elderly loved ones. But a harsh reality exists for residents of long-term care facilities. The World Health Organization (WHO) estimates that 1 in 6 elderly patients in nursing homes and other community settings have been the victim of one or more types of abuse.

What’s perhaps even more disheartening is how Medicare, a federal health insurance program for seniors, may inadvertently allow nursing homes to escape accountability. Keep reading to learn how Medicare’s policies and regulations impact elder abuse rates and what to do if your loved one has suffered harm or neglect in a care facility.

Nursing Homes Funded by Medicare Want to Maximize Profits

The goal of any business is to generate revenue and make a profit, and nursing homes are no exception. But when it comes to caring for some of the most vulnerable people in society, the pursuit of profit can raise ethical questions. While organizations need to be financially sustainable, it becomes a serious problem when the maximization of profit margins takes precedence over patient care.

As a government-funded program, Medicare sets reimbursement rates for healthcare services. These rates may not always cover the full cost of providing care, and nursing homes may be tempted to cut corners to maintain their profit margins, like reducing staffing levels, lowering the quality of food and amenities, and delaying building maintenance or repairs.

The consequences of these actions can be severe for patients, who often experience neglect, abuse, and substandard living conditions as a result.

Abuse Cases Are Regularly Underreported

In 2019, a review of Medicare billing records by auditors from Health and Human Services revealed that in 2016 alone, approximately 6,600 abuse cases were not reported to the insurance company.

While the auditors’ findings underscore the scale of the problem, it’s important to recognize that underreporting isn’t limited to a single year or a specific facility. It’s a systemic issue that permeates the entirety of the elder care industry, and it’s one that Medicare doesn’t take a proactive enough approach to addressing.

Fundamental Gaps Exist in Medicare’s Regulatory Policies

The underreporting of abuse cases in nursing homes is, in part, a byproduct of Medicare’s regulatory framework. As the primary payer for nursing home services in America, the company plays a critical role in overseeing the quality of care the facilities they reimburse provide to the insured. Yet fundamental gaps exist in Medicare’s policies that prevent them from effectively doing so.

One of the main issues is that reporting requirements are vague and leave too much room for interpretation about what does and doesn’t qualify as abuse. On top of that, Medicare relies on nursing homes to self-report, which is generally against the facility’s best interest. This means care homes often have a vested interest in hiding incidents of abuse.

The Citation Appeals Process is Secret

In the event that a nursing home is cited for a violation, Medicare allows for a secretive appeals process that remains confidential and prevents communities from becoming aware and holding facilities publicly accountable.

The appeals process can take years and happens behind closed doors, making it hard for families of nursing home residents to access information about the investigation about their loved one’s abuse. Facilities may use the appeals process to delay or reduce penalties, which can ultimately result in families failing to obtain justice.

When to Get Legal Help After Your Loved One Was Hurt in a Nursing Home

If you suspect your loved one has been abused or neglected in a care facility, it’s important to take action right away. The signs of nursing home abuse can include unexplained injuries, sudden changes in behavior, difficulty with eating or sleeping, or unexplained financial transactions. Be aware that if the nursing home fails to provide you with clear, concise, and honest explanations for any injuries or neglect, this is an immediate red flag.

A qualified attorney can help you through the complicated and often disheartening process of dealing with nursing home investigations, gathering evidence, and going back and forth with Medicare. They can handle phone calls, paperwork, and other red tape while you focus on taking care of your elderly family member.

At Mazow | McCullough, PC, we have helped dozens of families hold nursing homes and their staff accountable for harm they cause. We can provide you and your loved one with the compassionate, zealous legal advocacy you need now – just contact our Salem, MA office at (978) 744-8000 or toll-free at (855) 693-9084.

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