Kusserow’s Corner: Hospice Fraud

Fraud and abuse in the hospital setting was the subject of a recent HHS Office of Inspector General (OIG) report by the Office of Evaluation and Inspection (OEI). They noted that the goal of hospice care is to help terminally ill beneficiaries continue life with minimal disruption and to support beneficiaries’ families and caregivers throughout the entire process. It includes pain control, symptom management, and counseling for beneficiaries and their families in an effort to make the last days of a beneficiary’s life as comfortable as possible. Clearly, this type of care is both important and personal, yet hospice care in the Medicare program does not escape the problems of fraud, waste, and abuse. This spotlight page highlights this issue and the OIG’s efforts to eliminate it. They also explained that hospice general inpatient care (GIP) is for pain control or symptom management provided in an inpatient facility that cannot be managed in other settings. The care is intended to be short-term and is the second most expensive level of hospice care. GIP may be provided in one of three settings: a Medicare-certified hospice inpatient unit, a hospital, or a skilled nursing facility (SNF). CMS staff have expressed concerns about possible misuse of GIP, such as care being billed for but not provided, long lengths of stay, and beneficiaries receiving care unnecessarily. To be eligible for Medicare hospice care, a beneficiary must be entitled to Part A of Medicare and be certified as having a terminal illness with a life expectancy of 6 months or less. The hospice care may be provided in various settings, including the home or a nursing facility. This care is palliative—improving quality of life—rather than curative—curing the illness.

In another earlier study, the OIG reported they identified a number of compliance issues with hospice claims and Medicare requirements, citing eighty-two percent of hospice claims for beneficiaries residing in nursing facilities did not meet Medicare coverage requirements, totaling $1.8 billion. ( Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements) Sixty-three percent of Medicare hospice claims did not meet the plan-of-care guidelines, which state that hospices must establish a plan of care for each beneficiary describing what is supposed to be done, by whom, at what time, and for what purpose.

Hospice care is paid for by Medicare at different levels: palliative care, continuous home care, also known as “crisis care,” is available to patients who are experiencing acute medical symptoms, which result in a brief period of crisis, requiring skilled nursing services on a short-term basis. It differs from the standard hospice benefit, which does not require skilled care. Crisis care allows the patient to receive more emergent care in the comfort of his home. Due to its nature, crisis care is the most expensive hospice benefit provided by Medicare. The Federal government in a number of cases brought actions against hospice care centers that knowingly submitted false claims to Medicare for crisis care services that were not necessary, not actually provided, or not performed in accordance with Medicare requirements.

In one recent case, Matthew Kolodesh, the owner of a Northeast Philadelphia hospice business was convicted of defrauding Medicare of more than $14 million The problem is that those claims were for patients that were not eligible for Medicare, or for patients who didn’t receive the hospice services that were billed. In another case, Regina Swims King, the owner of Angelic Hospice in Mississippi was charged with running a multimillion dollar Medicare fraud and is awaiting trial, scheduled for December Regina Swims-King. The hospice served numerous counties in the Mississippi Delta and billed Medicare more than $11 million. Prosecutors said a hospice recruiter went door-to-door asking whether residents needed their blood pressure checked and then the hospice their information to bill Medicare for services, prosecutors said.

The most recent case is where Hospice of the Comforter Inc. (HOTCI), headquartered in Altamonte Springs, Fla., has agreed to pay $3 million to resolve allegations that it violated the False Claims Act by submitting false claims to the Medicare program for hospice services provided to patients who were not eligible for the Medicare hospice benefit. The government alleged HOTCI engaged in practices that resulted in billing Medicare for patients who were not terminally ill. Specifically, HOTCI allegedly directed its staff to admit all referred patients without regard to whether they were eligible for the Medicare hospice benefit, falsified medical records to make it appear that certain patients were eligible for the benefit when they were not, employed field nurses without hospice training, established procedures to limit physicians’ roles in assessing patients’ terminal status and delayed discharging patients when they became ineligible for the benefit. In addition, HOTCI’s former Chief Executive Officer Robert Wilson has agreed to a three-year, voluntary exclusion from Medicare, Medicaid and other federal health care programs.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2013 Strategic Management Services, LLC. Published with permission.