A Texas healthcare company has agreed to pay $990,478.46 to resolve allegations they violated the False Claims Act by submitting claims to Medicare for non-covered hospice services. The settlement resolves allegations that the company knowingly submitted false claims from May 12, 2017, through Jan. 31, 2022. The claims allegedly involved hospice services for patients who were not eligible for, and did not qualify for, the hospice benefit in violation of the False Claims Act.
Hospice care is special, end-of-life care intended to comfort terminally ill patients. To be eligible for the Medicare hospice benefit, a patient must be “terminally ill,” meaning that the patient has a medical prognosis that their life expectancy is six months or less if the illness runs its normal course.
“[The healthcare company] didn’t just unscrupulously rob the Medicare program out of hundreds of thousands of dollars, it also took advantage of ill patients who were unknowingly used for its scam,” said Special Agent in Charge James Smith of the FBI. “This type of healthcare fraud affects everyone — individuals and businesses alike. It raises our health insurance premiums, exposes patients to unnecessary medical procedures, harms patients and increase taxes, not to mention the billions of dollars in losses every year. The FBI will continue to work with our partners, including the private sector, to identify and disrupt health care fraud.”
The settlement includes the resolution of claims a former employee of the company brought under the qui tam or whistleblower provisions of the False Claims Act. The US Attorney’s Office jointly conducted the investigation with DHHS – Office of Inspector General and the FBI.
Compliance Perspective
Issue
All medical services that are provided must be medically necessary, and the patient or resident must be eligible for the services that are provided and involved in the decision to choose those services. Individuals receiving hospice services must meet specific criteria to be eligible for the program, including having less than six months to live. Providing medical services that are not necessary can be considered a false claim. Failure to promptly report a false claim or a kickback can result in lawsuits, fines, and other sanctions.
Discussion Points
- Review your policies and procedures on enrolling a resident into a hospice program in your facility. Update as needed.
- Train staff on the criteria that must be met to enroll a resident into the hospice program. Additionally, train nursing staff and social services on the procedure to follow for receiving or making hospice referrals. 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.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
