An Introduction to Whistleblower Lawyers and False Claims Act

Hospice fraud in South Carolina and the United States is an increasing problem as the number of hospice patients has exploded over the past few years. From 2004 to 2008, the number of patients receiving hospice care in the United States grew almost 40% to nearly 1.5 million, and of the 2.5 million people who died in 2008, nearly one million were hospice patients.

Most hospice care patients receive hospice care in private homes (40%). Other locations where hospice services are provided are nursing homes (22%), residential facilities (6%), hospice inpatient facilities (21%), and acute care hospitals (10%).

Medicare pays hospice agencies a daily rate for each day a beneficiary is enrolled in the hospice benefit and receives hospice care. The daily payments are made regardless of the amount of services furnished on a given day and are intended to cover costs that the hospice incurs in furnishing services identified in Nashville Whistleblower Attorney the patient’s plan of care.

The length of service is dependent on a number of different factors, including but not limited to, the type and stage of the disease, the quality of and access to health care providers before the hospice referral, and the timing of the hospice referral. In 2008, the median length of stay for hospice patients was about 21 days, the average length of stay was about 69 days, almost 35% of hospice patients were or died discharged within 7 days of the hospice referral, and only about 12% of hospice patients survived longer than 180 days.

This cap is determined by adjusting the original hospice patient cap of $6,500, set in 1984, by the Consumer Price Index. The Medicare Claims Processing Manual, at Chapter 11 – Processing Hospice Claims, in Section 80.2, entitled “Cap on Overall Hospice Reimbursement,” provides in pertinent part as follows: “Any payments in excess of the cap must be refunded by the hospice.”

Since 2008, there were about 4,700 places which were offering hospice treatment in the USA, which stood for regarding a 50% boost over 10 years. There had to do with 3,700 firms and also companies which were giving hospice solutions in the USA. Regarding fifty percent of the hospice treatment companies in the USA are for-profit companies, and also regarding fifty percent are charitable companies.
General Review of the Medicare as well as Medicaid Programs

While most hospice health care organizations provide ethical and appropriate treatment for their hospice patients, because hospice eligibility under Medicare and Medicaid involves clinical judgments which may result in the payments of large sums of money from the federal government, there are tremendous opportunities for fraudulent practices and false billing claims by unscrupulous hospice care providers. As recent federal hospice fraud enforcement actions have demonstrated, the number of health care companies and individuals who are willing to try to defraud the Medicare and Medicaid hospice benefits programs is on the rise.A recent example of hospice fraud involving a South Carolina hospice is Southern Care, Inc., a hospice company that in 2009 paid $24.7 million to settle an FCA case. In 2008, the median length of stay for hospice patients was about 21 days, the average length of stay was about 69 days, almost 35% of hospice patients were or died discharged within 7 days of the hospice referral, and only about 12% of hospice patients survived longer than 180 days.

The Social Security Act, at 42 U.S.C. § 1395y( a), limits Medicare hospice benefits, providing in pertinent part as follows: “Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for services or items- … (C) in the case of hospice care, which are necessary and not reasonable for the palliation or management of terminal illness …” 42 C.F.R. § 418.50 (hospice care must be “reasonable and necessary for the palliation and management of terminal illness”). Medicare pays hospice agencies a daily rate for each day a beneficiary is enrolled in the hospice benefit and receives hospice care.

The Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is the federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid.Over the past forty years, the Medicare Program has enabled the disabled and elderly to obtain necessary medical services from medical providers throughout the United States. Critical to the success of the Medicare Program is the fundamental concept that health care providers accurately and honestly submit bills and claims to the Medicare Trust Fund only for those medical treatments or services that are legitimate, medically necessary and reasonable, in full compliance with all laws, regulations, rules, and conditions of participation, and, further, that medical providers not take advantage of their disabled and elderly patients.

The Social Security Act, at 42 U.S.C. § 1395y( a), limits Medicare hospice benefits, providing in pertinent part as follows: “Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for services or items- … (C) in the case of hospice care, which are necessary and not reasonable for the palliation or management of terminal illness …” 42 C.F.R. § 418.50 (hospice care must be “reasonable and necessary for the palliation and management of terminal illness”). Palliative care is defined in the regulations as “patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.

While most hospice health care organizations provide ethical and appropriate treatment for their hospice patients, because hospice eligibility under Medicare and Medicaid involves clinical judgments which may result in the payments of large sums of money from the federal government, there are tremendous opportunities for fraudulent practices and false billing claims by unscrupulous hospice care providers. As recent federal hospice fraud enforcement actions have demonstrated, the number of health care companies and individuals who are willing to try to defraud the Medicare and Medicaid hospice benefits programs is on the rise.A recent example of hospice fraud involving a South Carolina hospice is Southern Care, Inc., a hospice company that in 2009 paid $24.7 million to settle an FCA case. Consumers need to protect themselves from unethical hospice providers, and hospice employees need to guard against knowingly or unwittingly participating in health care fraud against the federal government because they may subject themselves to administrative sanctions, including lengthy exclusions from working in an organization which receives federal funds, enormous civil monetary penalties and fines, and criminal sanctions, including incarceration.

Like Medicare, the Medicaid Program depends on health care providers to accurately and honestly submit bills and claims to program administrators only for those medical treatments or services that are legitimate, medically necessary and reasonable, in full compliance with all laws, regulations, rules, and conditions of participation, and, further, that medical providers not take advantage of their indigent patients.To be covered, hospice services must meet the following requirements. The individual must elect hospice care in accordance with § 418.24. That plan of care must be established before hospice care is provided.