A California doctor who worked for two Pasadena hospices was sentenced on December 16, 2024, to 24 months in federal prison for defrauding Medicare out of more than $3 million through claims for medically unnecessary hospice services. He was also ordered to pay $3,289,889 in restitution.
From July 2016 to February 2019, the doctor and a co-defendant submitted nearly $4 million in false claims for hospice services provided by two hospice companies. The co-defendant controlled both companies.
The doctor falsely certified on claims forms that patients had terminal illnesses, making them eligible for Medicare-covered hospice services. He typically accepted diagnoses provided by hospice employees, regardless of their accuracy. Additionally, he was not the patients’ primary care physician and did not consult with their actual physicians regarding their conditions. As a result, Medicare paid claims supported by the doctor’s fraudulent certifications and recertifications of patients.
In total, approximately $3,917,946 in fraudulent claims were submitted to Medicare, of which about $3,289,889 was paid.
According to the Medical Board of California, the doctor is licensed to practice in the state but has been on probation since 2015, with restrictions on his medical practice.
The co-defendant remains at large. Another individual, who allegedly recruited patients for the hospice companies in exchange for illegal kickbacks, has pleaded not guilty and is scheduled to go to trial on March 4, 2025.
Compliance Perspective
Issue
All medical services provided must be medically necessary, and the patient or resident must be eligible for the services being provided. They should also be actively involved in the decision-making process regarding the services. Medicare covers hospice services only for terminally ill patients, defined as those with a life expectancy of six months or less if their illness follows its normal course. Providing medically unnecessary services can result in false claims, and failing to promptly report a false claim or kickback could lead to lawsuits, fines, and other sanctions.
Discussion Points
- Review and update policies and procedures related to hospice services to ensure they are accurate, compliant with current regulations, and reflect best practices.
- Train all relevant staff (including medical, nursing, and social services) on the eligibility criteria that must be met for a resident to be enrolled in the hospice program. Ensure that staff are well-versed in the regulations governing hospice care, including the six-month life expectancy rule. Additionally, train staff on the correct procedures for receiving and making hospice referrals to ensure the process is handled appropriately, and that referrals meet Medicare’s requirements.
- Conduct periodic audits to ensure that residents enrolled in hospice programs meet the eligibility criteria for hospice care and that all necessary documentation is in place to support the need for such services. Audits should verify that all documentation is accurate and reflects the resident’s condition and prognosis, ensuring that the services provided are medically necessary and comply with regulatory standards.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
