Many hospices provide excellent care to loved ones at times when they need it most. However, the few dishonest ones can take an economic and personal toll on terminally ill patients at the end of their lives when they are at their most vulnerable. Fraud makes care more expensive than necessary and diverts government funding.
If hospice fraud involves false claims to Medicaid or Medicare, the False Claims Act empowers families of patients, employees or any other individuals with knowledge about fraudulent claims to report them. The qui tam provision of the act entitles whistleblowers to a portion of any funds the government recovers.
1. Enrolling patients fraudulently
Enrollment fraud takes many different forms. Lawsuit Legal offers fraudulent research that takes place in hospices. One common type is enrolling patients who are not terminal. Medicare reimburses daily treatment costs of these patients.
Another type of enrollment fraud that is more dangerous to patients is when hospices provide fraudulent information to a hospital or the family of a patient and divert those who need curative care to the hospice.
These patients still have a chance to recover but they do not receive the curative care they need at hospice which collects reimbursement while patients don’t receive the right standard of care and may die.
2. Offering fraudulent bills
There are many types of billing fraud. Hospices may offer fraudulent bills by reporting that a higher level of care was provided than a patient received. Each level of care is reimbursed at a different rate.
Patients often switch rapidly between different care levels depending on their needs and so accurate billing can be difficult. However, if hospices deliberately and knowingly charge for a higher level of care, they may be forced to return the payments in addition to paying civil penalties if they are reported.
Hospices may also do double-billing whereby they collect payment from Medicare and then also charge the patient’s insurance for services. As Medicare’s Hospice benefit is fairly complex, patients and their families may not be any the wiser.
3. Using caregivers instead of qualified professionals
Hospices may cut costs by paying much lower rates to unqualified caretakers instead of using doctors, registered nurses or other qualified medical professionals. The Medicare rates are carefully researched and measured to provide for payment of these professionals.
Hospices benefit financially when they use unqualified staff and instruct them to perform services a qualified person should perform. This puts them at risk of being prosecuted under the False Claims Act. Unqualified care can result in injury to patients and caregivers may risk being stripped of any caregiving qualifications and even criminal prosecution.’
4. Withholding services to in-home care patients
Hospices may deliberately withhold services to in-home care patients to convince them to enter inpatient care. The daily care amount for in-home care patients is much lower because fewer services are required.
This may mean refusing to provide treatment that is clearly part of Medicare’s home care benefits and opens a hospice up to prosecution under the False Claims Act. It also violates the rights of the patient to receive such care.
5. Cultivating improper referral relationships with nursing homes
Patients often come directly from nursing homes to hospice. Hospices may, therefore provide privileges and gifts to nursing homes in exchange for referrals. They may provide staff to the nursing home to provide certain services at the expense of the hospice or offer free goods to the nursing home.
They may pay compensation to a nursing home for services that have already been compensated by Medicare. Many such practices directly break the anti-kickback statute.