The Medicare and Medicaid system is administered through the payment of invoices submitted by healthcare providers. When submitting a claim to a government healthcare agency, it must be an honest amount for services actually rendered. The patient care cannot be the result of an unlawful kickback scheme and all care services rendered must adhere to the guidelines set forth for reimbursement eligibility.
When it comes to Medicare reimbursement for hospice care, the patient, facility, and treating physician must at all times abide by the hospice eligibility rules. Any invoices for services that are outside the eligibility procedures will be denied. As well, if a hospice facility is found to be submitting invoices for services that do not comply with federal rules, it could face significant liability under the False Claims Act – a federal statute designed to prevent fraudulent misuse of taxpayer funds.
United States ex. rel. Stone v. Hospice of the Comforter, Inc.
A Florida-based hospice care center recently remitted $3 million to settle claims it submitted unlawful invoices for certain services that were not actually Medicare-eligible. Within the Medicare guidelines are certain requirements that must be met in order for medical charges to be reimbursed by Medicare. These include only treating patients who meet the criteria for hospice service (i.e., suffering from a terminal illness), employing only nurses with heightened training in hospice/palliative care, requiring a physician to monitor a patient’s status to ensure the patient continues to meet the definition of “terminal,” and promptly discharging patients when they no longer meet this definition.
According to its whistleblower complaint, a former employee of Hospice of the Comforter alleged its employer failed to adhere to these guidelines and routinely submitted invoices for care that should not have been covered. The United States opted to intervene in the case in 2012 and, at the time, stated, “….We will continue to protect this important component of the Medicare program by ensuring that entities providing hospice care are only treating, and billing for, qualified patients.” Further, “Some of the most vulnerable people in our district rely on hospice services,” said Robert O’Neill, U.S. Attorney for the Middle District of Florida. “It is critically important that Medicare remains solvent in order to provide hospice benefits, and that we confront those whose practices in this area put economic gain before patient care.”
In a statement issued by the Department of Justice, it refers to the defendants’ business practice of admitting patients who were not necessarily eligible for hospice care in that a doctor had not determined the patient was likely to die within six months. In addition, regulations require patients to cease seeking curative treatments while in hospice care – a requirement not always followed by Hospice of the Comforter. Medicare and Medicaid do not allow coverage for both hospice care and curative care contemporaneously.
Upon settlement with the defendants, the Department of Justice reiterated its position against the unlawful use of Medicare funds: “Hospice care is a sacred trust from which no provider should fraudulently profit,” said Inspector General of the U.S. Department of Health and Human Services Daniel R. Levinson. “Claiming tax dollars for people who are not terminally ill and therefore ineligible for hospice care cannot be tolerated.”
Help Protect End-of-Life Care
Medicare is becoming increasingly cash-strapped, and will only get worse as the population ages. For these reasons, it is imperative that anyone with knowledge of fraud perpetuating through the palliative care system report their information to a reputable whistleblower attorney right away. The less money pilfered away from honest centers, the more that is available for those who truly need end-of-life care and the facilities who practice integrity on a daily basis.