The owner and administrator of Texas-based hospice and home health entities have been named in a multimillion-dollar whistleblower lawsuit. The two men, both 51, were convicted of criminal healthcare fraud and conspiracy charges in 2019.
On April 7, 2022, a civil complaint was filed against the two men, which alleges that they conspired to violate the False Claims Act by submitting false and fraudulent claims to Medicare for medically unnecessary hospice and home health services. Additionally, the civil complaint alleges that they paid illegal kickbacks to medical directors for patient referrals and created false patient medical records in support of the false and fraudulent claims. These included hospice and home health certifications that were material to Medicare payments.
The men are currently in federal prison for their criminal convictions. The owner is serving 240 months and was ordered to pay $120 million in restitution to the Medicare program. The administrator is serving 180 months. The Unites States is also entitled to recover triple the damages for violations of the civil False Claims Act as well as civil monetary penalties between $11,803 and $23,607 for each false claim submitted to Medicare.
Issue:
All medical services that are provided must be medically necessary, and the residents must be eligible to receive these services. This includes hospice services which require an admitting diagnosis that meets the criteria for the hospice program. Providing and billing for unnecessary medical services can be considered a false claim. Failure to promptly report a false claim or kickback can result in lawsuits, fines, and other sanctions. An effective compliance and ethics program can reduce fraud, waste, and abuse of government funds and prevent and detect criminal, civil, and administrative violations and promote quality of care, which includes preventing submission of false claims or offering of illegal kickbacks.
Discussion Points:
- Review your policies and procedures on enrolling a resident into a hospice program in your facility. Additionally, review your policies and procedures for operating an effective compliance and ethics program, and ensure identifying and reporting of false claims or kickbacks is part of your policy. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train appropriate staff on the criteria that must be met to enroll a resident into the hospice program and on the procedure to follow for receiving or making hospice referrals. Additionally, train all staff on your compliance and ethics policies and procedures upon hire and at least annually regarding what may be considered a false claim or kickback. Document that these trainings occurred and file each signed document in the employee’s education file.
- Periodically audit to ensure that residents enrolled in hospice programs meet eligibility criteria, and that documentation is sufficient to support the need for hospice services. Additionally, periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any concerns or violations to their supervisor, the compliance officer, or via the anonymous hotline.
