Massachusetts Attorney General Files Charges Against Nursing Home Owner for Medicaid Fraud

The Attorney General of Massachusetts has filed charges against another nursing home operator for Medicaid fraud. Carolyn Wetterberg is accused of fraudulently billing Medicaid over $600,000 for services that were never provided.

Carolyn Wetterberg, was co-owner and manager of Wetterberg Nursing Homes, which operated the Pond View Nursing Facility. Located in Jamaica Plain, Massachusetts, Pond View was a 43-bed long-term-care nursing facility.

Massachusetts Attorney General Martha Coakley’s Medicaid Fraud Division first learned of Pond View’s fraudulent activity after someone left them an anonymous tip. The Fraud Division team immediately began an investigation into the tipster’s claims and found that there was definite reason for concern.

Once the investigation was underway, it was discovered that Wetterberg was committing egregious acts of Medicaid fraud against the state. Authorities discovered that patients who were admitted to Pond View Nursing Facility were ultimately given a medical status that was inappropriate. Wetterberg would often classify a patient’s medical status at a higher level of care than they actually required, then bill Medicaid for those high-level services. This scheme was achieved through Wetterberg’s use of the Management Minute Questionnaire’s (MMQs) for resident patients.

Management Minute Questionnaire’s

In the state of Massachusetts, long-term care facilities ultimately receive reimbursement from Medicaid (MassHealth) through the information that is contained in a MMQ form. Each new resident in a nursing home facility is evaluated, then a MMQ form is completed. Facilities are reimbursed for the care that is equivalent to each patient’s nursing requirements and level of skilled care that is provided.

The MMQ form establishes multiple categories of patient care. Things like activities of daily living, ambulation status, continence and required eating assistance are evaluated. A score is developed using information gathered from each category, dependent upon the level of care required. For example, if a patient is able to walk on their own with no assistance, they are deemed independent. Medical records are also used to develop the proper MMQ scores.

Using the total MMQ score, Mass Health is able to assign each patient with a corresponding level of function. This score ultimately determines the rate of Medicare reimbursement for each patient. The higher the score, the more money the nursing home is reimbursed by Medicaid.

Details of the Medicaid Fraud Scheme

When authorities began digging deeper into the claims of Medicaid fraud at Pond View, they found that once patients were transferred to other facilities, their MMQ scores dropped in drastic numbers. According to official documentation, between the years of 2003 and 2008, Wetterberg orchestrated an ongoing Medicare fraud scheme that consisted of intentionally inflating MMQ scores of Pond View residents.

When investigators compared several patient’s Pond View records with their records in a different nursing facility, they discovered that Wetterberg had drastically exaggerated their disabilities. The evidence allegedly showed that residents whom Wetterberg claimed needed assistance walking were, in fact, able to walk on their own. Those residents whom Wetterberg claimed to be incontinent were actually continent. Multiple residents who were supposed to need assistance when eating were actually able to feed themselves with no problem.

Using the MMQ Medicaid fraud scheme, Wetterberg allegedly defrauded MassHealth for approximately $600,000 in services that were not only medically unnecessary, they were never provided.

Additional Issues

According to the official court documents, Pond View Nursing Facility had previously been shut down by the Massachusetts Department of Public Health during 2008. The closure was due to the extremely poor quality of nursing care that the facility was providing patients. This closure triggered the transfer of each patients within the 43-bed facility. Once admitted to new skilled nursing homes, each patient was again evaluated and assigned a new MMQ score. These new scores would later serve as evidence that Wetterberg committed Medicaid fraud by knowingly increasing MMQ scores for profit.

State Rep. Jeffrey Sánchez told the Gazette the sale might turn out to be good news for the state. “If they are found guilty, they are going to have to make restitution with the Commonwealth,” he said.

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