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Hospice Fraud

Hospice Fraud & End of Life Care Misconduct

What is Considered Hospice Fraud?

Hospice care is defined by the Federal Code of Regulations as a “comprehensive set of services … to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members.” Such end of life care is often provided using taxpayer dollars through federally funded programs such as Medicaid and Medicare. Hospice care through Medicare or Medicaid is available for terminally ill patients with a life expectancy of six months or less if their illness were to run its natural course. In order to receive hospice care a patient must be certified terminally ill by a physician. Hospice care services can be provided in the home or at a nursing home facility and are often accompanied by palliative treatment focused on pain and stress relief. Once a patient elects hospice care they can no longer pursue curative treatments, unless they are under 21 years of age.

What constitutes hospice fraud?

The U.S. Department of Health and Human Services, Office of Inspector General recently audited Medicaid hospice providers and identified a number of transgressions ranging from inappropriate billing resulting in over-payments, poor patient care, submission of claims that did not meet care standards, medical records that did indicate terminal illnesses and providing misinformation to patients and caregivers. When done knowingly these actions would constitute fraud against the federal government and give citizens the right to seek justice on its behalf.

General Hospice Fraud Scenarios

Hospice Enrollment Fraud
Failure to provide information to patients, family and caregivers
Overbilling and Improper Billing Overview
- False Medicare Claims for Continuous Home Care Services
Poor Standards of Care
Untrained/Unqualified personnel treating patients

Hospice Enrollment Fraud

One type of hospice fraud that occurs perhaps most commonly is when providers falsely admit patients into hospice care who were not actually terminally ill. Such patients will often be discharged after eventually submitting substantial Medicare or Medicaid bills, others have been kept in Hospice unnecessarily for years while the provider continues to collect benefits. However this comes not only at a cost to taxpayers, but also at a danger to the patient who may stop seeking curative treatment while in hospice. This false enrollment may occur with or without the patient’s knowledge.

In 2017 Chemed Corp. and Vitas Hospice Services (the largest for-profit hospice chain in the United States) agreed to pay $75 million to settle False Claims Act allegations that they incentivized employees with bonuses based on the number patients utilizing hospice care regardless of whether the patients may have benefited from curative care or were actually terminally ill.

In 2018, another hospice care provider, SouthernCare, agreed to pay $6 million to settle similar allegations that it knowingly admitted patients who were not terminally ill and even treated them for many years. In this case the Office of Inspector General warned that admitting patients who do meet the standards for hospice care can be extremely dangerous when patients who are not actually terminally ill stop seeking treatment for recovery.

Failure to provide information to patients, family and caregivers

A recent Office of Inspector General Report detailed how many patients, families and caregivers were not able to access crucial information needed to make informed decisions about whether hospice care was in their best interest. The report took issue with 35% of inpatient care election statements that were sampled and noted that hospice election statements are often missing required information or contain other vulnerabilities.

Overbilling and Improper Billing Overview

Hospice companies that bill the government at higher reimbursement rates than they are entitled to receive are committing fraud. A recent report from the Office of Inspector General concluded that inappropriate billing from hospices costs Medicare hundreds of millions of dollars. Examples of this include billing for services never provided, billing for higher levels of care than needed by the patient, and even enrolling patients who are not eligible for hospice care.

Proper documentation must be included in hospice certification and re-certification to show the patients continue to meet medical necessity, minimum disease-specific criteria, and support the proper level of care all associated with the progression of the terminal illness.

The four different levels of care for hospice payment include:

Routine Home Care
Continuous Home Care
Inpatient Respite Care
General Inpatient Care

Each different level of care results in a different reimbursement dollar amount that is given to providers. The level of care provided to hospice patients may change based on a number of different factors, including the medical condition and needs of the patient, as well as the patient’s access to loved ones and family members or other caregivers to assist in meeting those needs. Hospice providers are responsible for ensuring hospice patients’ medical records reflect the appropriate documentation to support the level of care for which they billed. Providers are subject to criminal prosecution under the False Claims Act when they bill for ineligible patients or bill at higher rates of care than were actually provided or necessary.

False Medicare Claims for Continuous Home Care Services

In a 2018 False Claims Act settlement for nearly $75 million dollars, a portion of the allegations dealt with hospice providers knowingly submitting false claims for continuous home care services that were not properly performed, were not performed at all or were not necessary based on the patient’s actual needs. Continuous home care services often provide the highest dollar reimbursement benefits for providers under the four different levels of hospice care which can result in hundreds of dollars more a day for each patient enrolled in home care versus routine hospice services. This level of care is reserved for patients experiencing acute medical conditions that cause a temporary period of crisis.

In this scenario the hospice provider allegedly set goals, utilized aggressive marketing campaigns and pressured employees to increase the number of continuous home care days billed regardless of actual patient need.

Poor Standards of Care

Untrained/Unqualified personnel treating patients

Many hospice facilities that are engaged in the types of fraud mentioned in this article including enrollment fraud, over billing, kickbacks for unqualified referrals and poor standards of care, do so with the use of untrained or unqualified personnel. In order to carry out these types of fraud many hospice facilities have allowed non-medical personnel such as administrators or accountants make medical decisions for patients based on financial, not medical needs.

In 2017 sixteen individuals were charged with a $60 million dollar hospice fraud scheme which included admitting and retaining patients who did not need hospice care, providing kickbacks to nursing homes and physicians who referred ineligible patients and even over drugging patients so that beneficiaries’ medical records would justify billing at a higher rate which sometimes resulting in injury or death. In order to do this they falsified and destroyed documents and regularly relied on non-medical personnel to do the work of physicians and nurses. The licensed physicians who were paid in the scheme actually provided little to no oversight. Care was often directed by a certified public accountant who had no medical licenses. Non-physician personnel would determine whether patients were deemed eligible to be under hospice care, at which level of care patients should be certified, as well as the type and amounts of drugs to be administered.They even provided physicians’ medical records login information to others so that they could falsify orders for services that had not been performed.

Many of the types of hospice fraud committed rely on the assistance of non-medical personnel. In this case and many others medical decisions would often be made without consulting a physician in an effort to put financial gain above patient care.

Florida Based Hospice Fraud Scenarios

Enrollment Fraud and Unnecessary Stays in Florida Hospices
Overbilling and Improper Billing in Florida Hospices
Overbilling and Improper Billing Overview
Improper kickbacks to health care professionals

Enrollment Fraud and Unnecessary Stays in Florida Hospice

Enrollment Fraud and unjustified stays in hospice are by far the most common and widespread violation in Florida.

In 2013 HPH Hospice (Hernando-Pasco Hospice) a Florida nonprofit corporation that provided hospice services throughout Hernando, Pasco, and Citrus counties agreed to pay $1 Million dollars to resolve claims that it knowingly encouraged improper admittance and submitted false Medicare / Medicaid claims for patients who did not actually need end of life care. Defendants allegedly had employees accept patients who did not need hospice care in order to meet goals set by management, failed to implement compliance programs, created procedures to discourage staff from discharging patients and instructed employees to falsify medical records all with the aim of admitting and extending stays for patients who did not need end-of-life care.

Also in 2013 Hospice of the Comforter Inc. (HOTCI) operating in Seminole, Osceola and Orange counties agreed to pay $3 million to resolve allegations that it knowingly submitted false claims to Medicare for patients who were not eligible for end-of-life care. In this case the whistleblower complaint alleged that the defendant directed employees to blindly admit all referred patients regardless of whether or not they were eligible for end of life care, falsified medical records to make patients appear to be eligible, delayed discharging patients and even established procedures to limit doctors roles in assessing patients terminal status.

In 2017 Haven Hospice, headquartered in Gainseville, FL, agreed to a more than $5 million settlement to resolve claims that it knowingly billed the federal government for medically unnecessary and undocumented hospice services. The hospice allegedly knowingly or recklessly failed to show valid reasons for patients’ initial hospice admittance and continued to collect medicare payments throughout their stay despite patients failure to show a decline in health. Haven retained some 63 patients who showed no signs of decline for three years and some patients up to six years.

Most recently in 2018, Health and Palliative Services of the Treasure Coast, Inc., The Hospice of Martin and St. Lucie, Inc., and Hospice of the Treasure Coast, Inc. agreed to pay $2.5 million dollars to settle allegations that they knowingly submitted false claims for services to hospice patients who were not terminally ill and were not eligible for such services under Medicare.

Overbilling and Improper Billing in Florida Hospices

In a 2013 Hernando-Pasco Hospice (HPH) False Claims Act settlement for $1 million which focused on fraudulent admittance throughout Hernando, Pasco, and Citrus counties whistleblowers also alleged that HPH fraudulently billed the federal government at higher reimbursement rates than it should have.

In 2015 Covenant Hospice, a nonprofit hospice care provider in Northwest Florida agreed to pay $10.1 million to the federal government for allegedly overbilling Medicare, Tricare and Medicaid. Of the four different levels of care for hospice payments, routine home care, continuous home care, inpatient respite care and general inpatient the highest reimbursement rate paid out by federal health care programs is for general inpatient care. In this case Covenant Hospice allegedly improperly submitted hospice claims for general inpatient care that should have been billed at the routine home care level.

Improper kickbacks to health care professionals

In 2017 Compassionate Care Hospice Group, a Florida Corporation, agreed to pay $2.4 million to resolve False Claims Act allegations that it improperly provided financial kickbacks to doctors in exchange for referrals to CCH Group Hospices. Specifically the whistleblower complaint alleged that the defendant paid illegal remuneration to five physicians in exchange for referring patients to hospice care and certifying that individuals were eligible for hospice services. The improper kickback consisted of direct payments to a medical director and phoney contracts with associate medical directors in exchange for referrals.

In a 2013 Hernando-Pasco Hospice (HPH) False Claims Act settlement for $1 million which focused on fraudulent admittance throughout Hernando, Pasco, and Citrus counties whistleblowers also alleged that HPH provided illegal kickbacks when it provided free services to skilled nursing facilities in exchange for patient referrals.