Massachusetts Attorney General Andrea Joy Campbell and the U.S. Attorney’s Office for the District of Massachusetts announced on Sept. 23 that RegalCare Management 2.0 LLC and RegalCare Management Group, LLC will pay $1 million to resolve claims that the nursing home operator inflated patients’ conditions to collect more from Medicare and MassHealth. The money resolves a civil case that began with a whistleblower’s lawsuit.
How a patient score turns into a payment
The attorney general’s announcement says the New York-based company falsely raised the health-status assessments of nursing home residents to win higher reimbursement. The scores at issue are Resource Utilization Group scores and Management Minute Questionnaire scores, which the state describes as the measures the operator manipulated. A higher score meant a higher payment from Medicare and MassHealth, the state’s Medicaid program, for the same resident. The state’s own headline calls the conduct a Medicare and Medicaid “price hike scheme,” and the accuracy of a resident’s paperwork in that setting moves money in both programs at once.
The U.S. Attorney’s Office described the allegations in more specific terms. The government said the operator submitted “Ultra High RUG” claims that were medically unreasonable and unnecessary, and that records were modified without assessing or speaking to patients or consulting clinicians. The settlement resolves allegations, and the announcements report no court finding.
Where the $1 million goes
Of the $1 million, $165,000 goes to the whistleblower who brought the case and $835,000 goes to the government, split between Medicare and Massachusetts Medicaid, according to the U.S. Attorney’s Office. The case is captioned United States and Commonwealth of Massachusetts ex rel. McCormick v. RegalCare Management 2.0, LLC, et al., No. 20-cv-11805-IT, in the District of Massachusetts. The “ex rel.” wording marks a suit filed by a private party on the government’s behalf under the False Claims Act.
The HHS Office of Inspector General’s enforcement listing carries the same announcement, summarizing the allegation as falsely increased assessments of patient health statuses to obtain more money from Medicare and MassHealth. Campbell said in the state’s release that “when nursing facilities falsify patient records and assessments to make more money off Medicare and MassHealth, it threatens the integrity of these essential programs.” U.S. Attorney Leah B. Foley leads the office that brought the federal side of the case.
The nursing homes tied to the company
According to the state, RegalCare has operated facilities in Holyoke, Greenfield, Worcester, Taunton, Quincy and Harwich since 2021. From April 2018 to February 2021 it also ran Maplewood Rehab and Nursing in Amesbury, Twin Oaks Rehab and Nursing in Danvers and Saugus Rehab and Nursing. The state’s announcement lists the buildings but, as read for this article, does not break out claims by facility or count the residents affected.
An earlier settlement from a therapy consultant
The government’s dealings with RegalCare had already produced one payment. In March, the U.S. Attorney’s Office announced that Stern Therapy Consultants would pay $315,000 to settle allegations that it conspired with RegalCare to submit false Medicare claims between Jan. 1, 2017, and Sept. 30, 2019. The office said the conduct included Ultra High RUG therapy after documentation showed patients should have stopped receiving it and billing for services that patients refused or could not perform. The release also alleged that a non-clinical director without a license certified the completion of services performed by a terminated employee. The whistleblower’s share of that settlement was $61,875. The March release identified Eliyahu Mirlis as RegalCare’s owner and Hector Caraballo as an executive, both named in the government’s case, which that release described as ongoing.
What a Medicare statement can and cannot show a family
The routine check that Medicare recommends is simple. Medicare asks members to compare the dates and services on their own calendars with the statements the program sends, making sure each listed service was received, according to Medicare.gov’s page on reporting fraud. The page recommends a Medicare.gov account for viewing Original Medicare claims once they are processed, and lists 1-800-MEDICARE (1-800-633-4227) for reports. Members of Medicare Advantage or a drug plan can call the I-MEDIC line at 1-877-772-3379, and online reports go to the inspector general’s site. The page also advises against giving a Medicare card, Medicare number or Social Security number to anyone other than a doctor, against accepting offers of money or gifts for medical care, and it points to identitytheft.gov for reporting medical identity theft.
A statement lists services and dates. The RegalCare allegations concern assessment scores recorded inside a facility’s own files, so a resident’s family would not necessarily see the inflated score on a statement, and the government’s case began with a whistleblower’s suit rather than a member’s report. The U.S. Attorney’s Office put the total at $1 million, with $835,000 going to the government side and split between Medicare and Massachusetts Medicaid.
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This article was produced with AI assistance and checked against the primary sources linked above.
David M. Keller is a finance writer based in Columbus, Ohio, covering personal finance and consumer-focused economic topics. He earned his degree in journalism from Ohio University and began his career reporting on local business and economic trends for a regional media outlet. Since then, he has contributed to a variety of online publications, focusing on clear, practical coverage of topics such as cost of living, debt, and everyday financial decision-making.
