Fighting Allegations of Hospice & Palliative Care Fraud

Navigating Allegations of Hospice & Palliative Care Fraud

Hospice and palliative care providers work hard to compassionately care for patients at the end of life. However, like any industry, there are occasionally bad actors who commit fraud. If you find yourself or your hospice organization accused of fraudulent billing practices or poor patient care, it can be stressful and frightening. This article provides an overview of common allegations, defenses, and steps to take if facing a fraud investigation.

Background on Hospice & Palliative Care

Hospice care focuses on comfort and quality of life for terminally ill patients expected to live six months or less. It covers services like nursing care, medical equipment, medication, spiritual counseling, and grief support. Medicare Part A covers hospice services for eligible beneficiaries. Palliative care provides relief from serious illness symptoms but doesn’t require a six-month prognosis.

To qualify for hospice, two doctors must certify the patient has less than six months to live if their illness runs its normal course. However, if patients live longer than six months, they can be recertified. There’s no limit on how long a patient can continue hospice as long as doctors recertify eligibility.

Common Allegations of Fraud

Several major types of fraud plague the hospice industry. Understanding the common allegations can help providers prevent issues and respond appropriately if accused.

1. Enrollment Fraud

This involves enrolling patients who aren’t eligible for hospice because they aren’t terminally ill. Tactics include:

  • Falsifying medical records to make patients appear sicker
  • Leaving out records with improving health indicators
  • Having business relationships with referring physicians (which incentivizes unnecessary referrals)

2. Services Fraud

Services fraud means billing for hospice services never performed. This can involve:

  • Billing for higher levels of care than provided
  • Billing for services after a patient’s death
  • Recording fake nurse visit notes

3. Kickback Schemes

Kickbacks refer to receiving payment in exchange for patient referrals. This includes:

  • Paying physicians/facilities for each referral
  • Providing free services, supplies, certifications, or other benefits to induce referrals
  • Waiving co-pays/deductibles to encourage patient enrollment

Defenses Against Allegations

No provider wants to face fraud charges, but if you do, several defenses may apply depending on the situation:

1. Lack of intent: Fraud requires you knowingly and willfully committed deception. Evidence showing actions weren’t intentional can defeat charges.

2. Clerical errors: Simply making billing mistakes doesn’t necessarily constitute willful fraud. Evidence that issues stem from clerical errors rather than intentional deceit can help avoid liability.

3. Industry standards: Demonstrating your actions aligned with common hospice industry practices can bolster defense arguments, especially for recordkeeping and eligibility issues.

4. Patient complexity: Terminally ill patients often have complex, unpredictable disease trajectories. Explaining why a patient lived longer than six months despite an accurate prognosis can help overcome recertification questions.

5. Self-reporting: Self-disclosing issues to authorities before an investigation begins can lead to reduced penalties and cooperation credit during sentencing.