Does submitting claims for reimbursement to Medicare and Medicaid for providing hospice care to residents who are not terminally ill constitute fraud and violate the False Claims Act?
Compliance Perspective – Fraud
Policies and Procedures: The Compliance and Ethics Officer, the DON and Administrator will review the policies and procedures regarding the requirements for a resident to be admitted into hospice care and the allowable claims that may be submitted for reimbursement to Medicare and Medicaid. Training: Staff will receive training on eligibility criteria for residents to receive hospice care and the protocol for assessing appropriate discharges from hospice care. Audit: Audits will be conducted periodically to ensure appropriate physician documentation exists supporting the terminal status of residents under hospice care. Audit results will be summarized and submitted to QAPI for review and recommendation, and followed-up by the Compliance and Ethics Committee.
The former owner of a Mississippi hospice pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud. The defendant admitted that she had submitted almost $12 million in fraudulent claims to Medicare and nearly $3 million to Medicaid during the time that she operated four separate hospice provider companies. The indictment in 2017 alleged that the fraud committed by the defendant spanned nearly 10 years.
A fine of $250,000 and up to 10 years in prison may be assessed to the defendant, and the government is also seeking the forfeiture of illegal gains and restitution. Her sentencing is scheduled for January 29, 2019.
The Centers for Medicare & Medicaid Services (CMS) found what it termed a “runaway problem” involving Mississippi hospice fraud. A federal investigation has resulted in at least eight convictions since 2014.
One of the signs of hospice fraud that CMS found is having a high number of patients placed under hospice care who outlive hospice care coverage because they are not terminally ill and are discharged.
Four other persons have been convicted or pleaded guilty for their roles in this case, and three others are under indictment.
