3 Major Types of Hospice Fraud

Hospice care is an essential service for those suffering from incurable illnesses or diseases. It provides comfort and cares for terminally ill patients and their families during the end of their life. Those who commit fraud or abuse against hospice patients or the hospice systems threaten the existence of hospice care.

People accused of committing hospice fraud face serious consequences. Their reputation is damaged, and they are forced to spend a lot of time and money fighting these charges. Anyone charged with these crimes benefits from hiring a hospice fraud defense attorney. These are criminal defense attorneys who can craft strong arguments in your defense and work to protect your rights.

What is Hospice Care?

Hospice care is specialized medical care for people living with a terminal or serious illness approaching the end of their lives. Unlike regular medical care that focuses on treating an illness or disease, hospice care focuses on making the person comfortable and managing their symptoms.

People enter hospice care after they decide to stop aggressive treatment of their terminal condition or illness. Hospice care centers around reducing a patient’s pain and alleviating symptoms caused by their condition. It’s meant to increase a patient’s quality of life for the time they have left.

Hospice provides comprehensive comfort care to patients and their families to address the physical, emotional, and spiritual distress experienced at the end of life. Hospice services include skilled nursing, managing medications, offering psychosocial and spiritual support, and providing needed medical equipment.

A team of doctors, nurses, home health aides, and other hospice staff work with hospice patients to develop a care plan according to the patient and their family’s wishes. Hospice care can be administered in the patient’s home and with the help of family members but is also available as an in-patient service in residential nursing facilities.

Hospice services are available to anyone who meets medical eligibility criteria. To meet the criteria, the patient’s doctor plus a hospice doctor must certify that the patient’s life expectancy is six months or less if their illness or disease is allowed to run its course.

Hospice care is available to people of any age with several conditions, including:

• All types of cancer
• Late-stage kidney, heart, or lung diseases
• Advanced stages of dementia or Alzheimer’s disease

Families rely on hospice care to ease their loved one’s pain and provide compassionate care during their last weeks or months. Hospice care also supports the patient’s family by offering grief and loss counseling during and after their loved one’s treatment.

What’s Considered Hospice Fraud

Hospice fraud is a form of fraud revolving around hospice care and hospice patients. It happens when caregivers, facilities, or organizations commit fraud against hospice patients or the public health systems responsible for covering hospice costs.

Hospice fraud can take place anywhere hospice services are provided. This includes hospice patients’ homes if they receive home care or skilled nursing or hospital-affiliated facilities.

Hospice fraud cases may result from improperly trained staff, billing errors, or schemes designed to take advantage of the system. Hospice fraud includes submitting false and fraudulent claims, fraudulent hospice enrollment, and forms of administrative fraud. Manipulating patient treatment to maximize billing or benefits in place of providing standard care is another form of hospice fraud.

Who can be accused of hospice fraud?

People who work within the hospice care system, including providers and administrators, can be accused of committing hospice fraud. This includes:

• Medical professionals such as doctors and nurses
• Employees of the facility providing hospice care
• Owners of the facility providing hospice care
• Administrators and licensees involved in the wrongful billing to Medicare

The 4 Major Categories of Hospice Fraud

Hospice fraud encompasses a broad range of fraudulent and abusive tactics, but some forms are more common than others. The four major types of hospice fraud are false claims, kickbacks, false diagnosis, and improperly delivered services or products.

False claims

Filing false claims through billing is a major form of hospice fraud. It’s used to defraud government-funded healthcare programs. Most false claims involve fraudulent billing to Medicare and Medicaid.

False claims of hospice fraud include:

• Double billing for their services: Asking hospice patients or their families to pay for services that are being reimbursed through their private insurance plan, Medicare, or Medicaid
• Charging patients for unnecessary services: Ordering medications or medical supplies for the patient that are not needed for their care.
• Manipulation for financial gain: Manipulating patients into receiving hospice care in a facility rather than at home and billing Medicare, Medicaid, or their insurance for a higher level of care

Improperly delivered services or products

Hospices do not always provide needed or adequate care to their patients. Improper care, called deficiencies, is a form of hospice fraud. A recent study by the Office of Inspector General at the US Department of Health and Human Services found that over 80% of the hospices they reviewed had at least one deficiency.

Hospices are paid per-diem, and they receive a fixed amount per day and per patient without regard to the number of services being provided, which incentivizes the hospice to perform fewer services. Examples of improper services or products are:

• Reducing the frequency of visits hospice staff make to patients’ homes, including check-ins by phone instead of in-person.
• Ordering insufficient medication to treat patients to save money.
• Using Licensed Practical Nurses (LPNs) to perform services that only Registered Nurses (RNs) are qualified to do.
• Manipulating hospice patients into receiving care at a facility instead of their home.

Kickbacks

Kickbacks are incentives hospice providers give to nursing homes for patient referrals. This type of fraud occurs when nursing homes enter semi-exclusive or exclusive agreements with hospice care providers for the end-of-life services for their nursing home patients.

Nursing homes and hospice providers both benefit from this relationship. Nursing homes offer hospice providers a large pool of potential clients and future profits. Hospice staff providing care in nursing homes helps free up responsibilities from nursing home staff, reducing their workload.

This increases the risk of hospice providers sending kickbacks to nursing homes when given more patients. It results in more hospice patients receiving hospice care that is not medically needed.

Kickbacks between nursing homes and hospice facilities take several forms:

• Hospice providers giving free or below market value goods or hospice skilled nursing services to nursing homes in exchange for patient referrals
• A hospice referring patients to nursing homes to encourage the nursing home to refer the patient back to hospice when that care is needed at a later date

Kickbacks are prohibited under Medicare and Medicaid. The Anti-Kickback Statute makes it illegal to knowingly or willfully receive, solicit, offer, or pay anything of value in exchange for patient referrals.

One other type of hospice fraud

To qualify for hospice care, doctors must certify their patient has six months or less left to live to receive Medicare coverage. If the patient improves and their life expectancy increases, the hospice is forced to discharge them from their care. Failing to report changes in the patient’s health or failing to get doctor certification is considered hospice fraud.

Impact of California Senate Bill 664

California SB 664 imposes a moratorium on new licenses to provide hospice services for one year, beginning on January 1, 2022. This law was created to allow more time for the California State Auditor to assess hospice fraud and abuse in the state, investigate fraud claims, and evaluate compliance with mandated reporting of hospice fraud. This means hospice care facilities will be more closely scrutinized for fraud over the next year.

The Consequences of Losing a Hospice Fraud Case

If you’re accused of hospice fraud and lose your case, you’ll face serious consequences that can impact your life, career, or hospice facility. It’s essential to understand how losing a hospice fraud case can negatively impact your business and personal life.

Financial consequences

Mounting a defense against hospice fraud charges is costly. You’ll be responsible for paying legal fees for the duration of your case and will face penalties if you’re convicted. The US Department of Justice isn’t afraid to seek significant damages from the guilty party. A recent sentence given to a hospice administrator found guilty of hospice fraud includes a restitution payment of over $2.1 million.

Loss of time

Hospice fraud cases can be complicated and involve time-consuming investigations and legal proceedings. It’s not unusual for these cases to take several years of your time. Hearings, depositions, and other legal matters take you away from your day-to-day activities and can negatively impact your job, hospice facility, and quality of life.

Losing a hospice fraud case can result in you serving significant prison time. The hospice administrator ordered to pay $2.1 million in restitution was also sentenced to 30 months in prison for his offenses. Prosecutors in a California case involving hospice facility owners are seeking a maximum total penalty of 35 years in prison if the defendants are found guilty.

Loss of reputation

Losing a hospice fraud case is devastating to your reputation and the credibility of your hospice care business. Cases involving hospice fraud gather considerable media attention, with information about the company and administration plastered in articles across the internet.

This affects you and your business’ reputation for years when families and patients search for hospice care services. Even a false accusation can negatively impact your reputation.

The Best Defense Against a Hospice Fraud Case

Hiring a top criminal defense attorney can help improve your outcome if you’ve been accused of hospice fraud. Hospice fraud accusations require expert legal assistance and time to clear the charges. These cases involve thorough investigations by multiple agencies. You need an experienced attorney for the best defense.

Consider hiring criminal defense attorney Mariya Melkonyan. Mariya’s 13 years of courtroom and jury trial experience as Deputy District Attorney provide an advantage for your hospice fraud case. She recognizes the most common forms of hospice fraud and uses her in-depth knowledge of hospice fraud laws to develop a strong defense strategy to fight accusations against you and your business.

Contact the Law Offices of Mariya Melkonyan for a consultation of your case.