Fraud in the American Hospice Care System
A newly released Inspector General Report from the Department of Health and Human Services exposes the vulnerabilities in the Medicare-funded hospice program. The report consolidates patient and Medicare payment data back to the year 2005 and concludes that some hospice care providers are neglecting patients and defrauding Medicare. The report calls into question the quality of hospice patient care as well as the financial integrity of the program itself.
Medicare pays for four levels of hospice care. In ascending order of cost of care the levels include routine home care, general inpatient care, continuous home care, and inpatient respite care. Medicare-certified hospices provide the care, and the facility may be for-profit, nonprofit or government-owned. Care can also be provided in the home, assisted living facility residences, skilled nursing or other nursing facilities. It is a complicated set of processes and regulations while the level of patient care needed keeps changing. Oversight of hospice industry practices needs to improve to stay affordable as a government program providing compassionate, end of life care. The Centers for Medicare and Medicaid Services is a crucial funding arm of these hospice services and are being charged to increase levels of scrutiny to detect problems.
DHHS Office of Inspector General Report
Incorrect or inappropriate hospice billing has cost hundreds of millions of dollars to the Medicare program. The current payment process incentivizes hospice providers to minimize services while seeking beneficiaries with uncomplicated needs. This tactic keeps the hospice cost down while overbilling Medicare for service levels that don’t match patient needs creating profit through fraud. Unlike many healthcare providers, a hospice is not paid per number of services performed but rather per patient per day regardless of the number of services provided. It has been reported that some patient needs have been ignored because of this billing practice. The report shows that fewer services are provided to patients over weekends though the patient’s needs had not changed from midweek. Some hospice facilities bill at the highest level of care category for weeks but the service provided might be a mere phone call to the family to check on the patients’ well-being.
Federal reviewers also found out that some hospice providers search for patients who reside in nursing homes or assisted living facilities as these environments provide cover to overbill Medicare for a level of service that was not needed but cost the government program almost four times that of basic, in-home care. The report cites in 2012 Medicare paid $268 million for the more expensive, inpatient hospice care for patients that did not need it. In one of the worst examples of outright fraud, a hospice owner signed up patients who were not terminally ill making them unqualified for hospice care at all. In another case, a new hospice patient did not understand that in signing into the hospice program the patient is waiving their right to Medicare payments for curative treatment. The patient was elderly, lonely and just wanted someone visiting them at home.
Not all hospice facilities ignore patient needs or commit fraud. To the contrary, most operate honestly and tend to patient needs with compassionate care. Hospice care is a gift to family members who cannot, or are not qualified to, care for their dying loved one. It reduces the pain and suffering of the patient and gives them a sense of safety as they approach their end of life. More baby boomers are joining the ranks of the elderly, and a strain will be placed on the sustainability of the hospice system. Oversight, review, and modifications to billing systems and patient care are critical to keeping costs and quality in check.
Education about the hospice world, knowing what to expect as a patient or as a family member of a patient is crucial to the best outcome experience for all involved. Like the hospice system itself, oversight and review of a hospice facility before the need arises in your family system allows for sound decision making at a time in life where calm and caring should be the focus.
If you have questions or need guidance in your planning or planning for a loved one, please do not hesitate to contact our Troy office by calling us at (434) 589-2958.