An insurance defense team came to us on a Michigan no-fault case brought by a residential care provider seeking payment for its charges.
The home was billing 24-hour attendant care plus a separate housing per diem for a resident recovering from a motor vehicle accident. From what counsel had seen, the resident was rarely at the home, and what was billed as attendant care looked more like general supervision. The home had also once held an adult foster care license but it had since lapsed.
That raised questions outside the usual medical-billing playbook. Was the home licensed for the level of care it was billing, and did the care described in the file match either the license or the charges?
THE NEED
An expert who could speak to both sides at once: the clinical reality of what attendant care involves, and the regulatory framework that governs whether a home is authorized to provide and bill for it.
A general medical billing expert wouldn’t have gotten there. Neither would a pure clinical expert with no licensing background.
THE REPORT
The report went well past the license. The expert identified that the provider couldn’t show records of staff training.
Care was billed as delivered at the home, but the evidence indicated it was delivered in the places where the resident actually lived, a model closer to home care, which the provider wasn’t set up to offer. Much of the supervision appeared to happen remotely, away from where the resident slept, which the expert opined fell below the standard of care for attendant care supervision. And incidents that could have been avoided weren’t documented or investigated the way most home care agencies would handle them.
The case settled before trial.
THE TAKEAWAY
A lapsed license is easy to read as a paperwork problem.
Here, it was a reason to check whether everything else matched the paperwork: training, where care actually happened, how closely the resident was supervised, and what was written down when something went wrong.
An expert who only checked the license would have stopped early.
Details in this case study have been altered to protect client and party confidentiality.
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