End-of-life care can be a sensitive subject. Sadness and the desire to make our loved ones comfortable can conflict with the incredible costs. But for those on Medicare and Medicaid, financial assistance exists for hospice care.
Hospice is an umbrella term that covers a large range of services for those who are expected to live less than six months. Hospice programs, which can be for-profit or non-profit, provide support to help dying patients have comfort and dignity, but not an expectation of a cure. Such palliative care programs cover patients at home—most hospice care is provided to those dying at home—but such treatment can also be provided in an acute-care hospital or skilled nursing facility.
Under Medicare Part A, virtually all of what encompasses hospice care is covered, for as long as the patient is alive.
It is a generous benefit, largely because it is impossible to say how long someone with a terminal illness will live. Thus, when the six-month time limit approaches, patients need to be recertified as needing care in order to remain in a hospice program. But this compassionate benefit, unfortunately, opens the door to fraud.
What Types of Hospice Fraud Occur?
We have a brief, but by no means comprehensive, list of the kinds of hospice-related frauds that commonly occur:
- Certifying someone as needing hospice care when they are not clearly terminally ill, and then re-certifying them every six months (Medicare does not pay for routine, non-terminal nursing home or assisted living costs.)
- Ordering unnecessary or redundant durable medical equipment and medication
- Paying incentives/kickbacks to referring sources (physicians, other nursing homes, etc.)
- Upcoding (billing for a higher level of service than was provided)
- Falsifying medical records in order to collect the hospice benefit
- Not obtaining a doctor’s certification for care plans
- Providing inadequate services. For example, refusing to provide oxygen or pain medication to a patient who obviously needs them, even though the hospice is getting paid to provide them.
- Using the lower-paid Licensed Practical Nurses (LPNs) or Home Health Aides for tasks that only Registered Nurses (RNs) can legally perform
- Reducing the frequency of visits to a home-care hospice patient
- Billing the family for costs or services that are reimbursed by the Medicare hospice benefit.
If you have a loved one entering hospice care, either at home or in a facility, make sure you understand what is contained in any contracts you sign. Additionally, do not let the hospice provider talk you into care you think is unnecessary, or out of care that you believe is medically necessary. The latter point is especially important if your loved one is not being kept comfortable, appears in distress, or if staffing appears inadequate or negligent.
The OIG is on the Case
In 2019 alone, Medicare spent over $20.9 billion on hospice care. Think about that figure for a moment.
The Office of Inspector General (OIG) has a strong incentive to investigate hospice fraud because of the billions of dollars paid out every single year, and because of that, hospice fraud has become an enforcement priority. OIG Special Agent in Charge Gerald T. Roy has said, “The decision to provide hospice services should be prompted by a patient’s terminally ill medical condition and desire for palliative care, not a hospice provider’s desire to boost its profits.”
Recent cases in which whistleblowers have made a difference in hospice care fraud include:
- Crossroads Hospice operating in Ohio and Tennessee, settled for $5.5 million in 2021 to resolve allegations that they violated the False Claims Act by submitting claims to Medicare for non-covered hospice services.
- Evercare Hospice and Palliative Care, a Minnesota-based hospice provider, will pay $18 million because of FCA allegations that it asked for Medicare reimbursement for patients who were not terminally ill. The whistleblower’s award in this 2016 case has not yet been determined.
- Joseph Hospice Entities and its majority owner Patrick T. Mitchell agreed in 2015 to pay $5.87 million under the FCA’s provisions because of allegations that they did not supply the continuous-care hospice-level treatment that they claimed they did. Continuous-care services are provided when a patient is in medical crisis and needs immediate, acute care. Three whistleblowers who brought the qui tam suit will split a little more than $1 million.
- In an ongoing case, Caris Healthcare, which operates seven locations in South Carolina, is potentially liable for millions stemming from a whistleblower’s allegations that the company asked for Medicare reimbursement for patients who were not terminally ill, while repeatedly re-certifying them as terminal.
Hospice fraud is a false claims area that will undoubtedly require more updates from us in the future.
Making a Difference
If you think you have the facts needed to bring a whistleblower case, the experienced whistleblower attorneys at the Louthian Law Firm can review your case and help you file the appropriate disclosure statement. Under some circumstances, the government will intervene, or join in your lawsuit.
Your chances of succeeding are greater if your whistleblower claim is substantive, clear, and to the point. Because of this, meeting with a qualified whistleblower attorney can increase your chances of winning. The Louthian Law Firm can help you form your claim so that the government will be more inclined to intervene in your case; government intervention can sometimes increase the chances of recovering reward money. Even if the government decides not to intervene, it could still be a good idea to pursue your case without government involvement. Our strong support system can assist you through every step of the process.
For a free, confidential evaluation of your case, call the Louthian Law Firm today at 1-803-454-1200 or, if you prefer, you can fill out our online contact form.