In today’s case, we look at the Nashville-based nonprofit hospice center Alive Hospice, who is alleged to have admitted patients who did not meet the criteria for hospice coverage, and to have intentionally defrauded the government by submitting claims on behalf of these patients.[1. Emily Kubis, “Alive Hospice pays $1.5M in False Claims settlement,” Nashville Post, September 10, 2015. http://nashvillepost.com/news/2015/9/10/alive_hospice_pays_15m_in_false_claims_settlement.] While Alive Hospice representatives publicly disagreed with the allegations, the hospital agreed to pay $1.5 million to the federal government and Tennessee’s Medicaid program TennCare.
Under state and federal Medicaid guidelines, coverage for round-the-clock palliative care in a hospice facility is reserved for patients enduring terminal, end-of-life medical conditions. In order to qualify for coverage, a patient must agree to forgo any additional medical treatments that are designed to treat and/or cure the underlying medical condition, and patient care turns its focus to comfort and pain management. Medicaid will currently cover hospice care services including room and board, doctor and nursing services, medical equipment and supplies, prescription drugs, pain relief, physical therapy, psychological therapy, dietary counseling, short-term inpatient care, and grief therapy for surviving family members.
More specifically, TennCare states the following with regard to hospice coverage: “Once an individual elects the hospice benefit, that individual has chosen to end curative treatment for his terminal illness. TennCare will not pay for curative services, including drugs, relating to the treatment of the individual’s terminal illness unless the individual is a child under age 21. TennCare will continue to pay for other services for illnesses not related to the terminal illness.”[2. TennCare Policy Manual, approved February 8, 2013. http://www.tn.gov/assets/entities/tenncare/attachments/ben07001.pdf]
Details of the allegations against Alive Hospice
According to the Department of Justice, Alive Hospice is alleged to have provided care to terminally ill patients beyond what is permitted by Medicaid and TennCare guidelines. These additional services resulted in a $6 million overpayment to Alive Hospice by state and federal Medicaid programs, but the company settled with the government for just $1.5 million.
In a statement from Alive Hospice, CEO Anna-Gene O’Neal said, “We absolutely disagree with the federal government on the evaluation of those specific patient cases. We feel confident in the level of care and the billing….The goal really here is to put this behind us because what’s really important is the care that we provide.”[3. Holly Fletcher, “Alive Hospice to pay $1.5M in overbilling settlement,” The Tennessean, September 10, 2015, http://www.tennessean.com/story/money/industries/health-care/2015/09/10/alive-hospice-pay-15m-overbilling-settlement/72001450/]
Nonetheless, the Department of Health and Human Services reiterated its position that the company engaged in intentional false billing, stating, “Providers are overbilling the Medicare program and taking advantage of patients at a particularly vulnerable point in their lives….HHS-OIG will continue to pursue providers who overbill these programs and will seek appropriate remedies through the U.S. Attorney’s Office.”[4. “Alive Hospice Pays U.S. And Tennessee Over $1.5 Million To Resolve False Claims Act Lawsuit,” September 10, 2015, United States Department of Justice, http://www.justice.gov/usao-mdtn/pr/alive-hospice-pays-us-and-tennessee-over-15-million-resolve-false-claims-act-lawsuit]
This case was brought to light by a former triage nurse of Alive Hospice who will receive $263,000 in exchange for her willingness to come forward.
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If you work in the healthcare industry and are aware of possible billing issues within the company, please contact Berger Montague to confidentially discuss your case.