Tuesday, December 22, 2015

United States Settles Civil False Claims Act Allegations Against Florida Hospice For More Than $3 Million. Case Study - Hospices' Need for Compliance Plans and Audit Issues.

The hospice industry has been under investigation by the Office of Inspector General and the subject of many Medicare health care fraud investigations for the past three years. California and Florida have have numerous investigations pending. These cases can proceed civilly under the qui tam false claims act, criminally or both. A recent case settled civilly which is expected to resolve any potential criminal investigation.

One redflag that triggers investigations is a hospice with patients who have lengths of stays in hospices greater than a year or patients who go from hospice to hospice. The issue in these cases is medical necessity and suspected marketing of patients where patients received hospice care from multiples agencies for over a year or two. Typically, federal healthcare programs only pay for hospice care when patients are in a terminal condition and are expected to live for less than six months. Hospice is intended to be palliative rather than curative.

In Jacksonville, Florida, the U.S. Attorney settled a civil qui tam lawsuit last month in which the government settled with Hospice of Citrus County (“HOCC”) for $3 million in restiution ($3,022,000 exactly). The allegations were that HOCC knowingly submitting false claims to the Medicare and Medicaid programs for medically unnecessary hospice care of more than 50 patients who had lengths of stays greater than 1,000 days. 

Despite the principle of hospice being for terminal patients with less than 6 months to live, HOCC allegedly treated more than 50 patients for lengths of stays in excess of 3 years. It was also alleged that HOCC knowingly billed the government for undocumented hospice services. The settlement resolved liability under the False Claims.

The specific allegations were that between June 1, 2009, and March 15, 2015, HOCC treated at least 52 patients with lengths of stay in excess of 1,000 days.  The government contends that for those 52 patients, HOCC either knowingly or recklessly failed to document a valid basis for the initial start of hospice care and/or subsequent hospice coverage.  The failure in documentation included no support for the length of hospice services; patient files that failed to document basic patient characteristics; and patient records that were either unsigned or signed with inconsistent practitioner information. 

In some cases, patients were allegedly admitted to HOCC simply because their spouse was in hospice care.  In other cases, patients were allegedly admitted to HOCC under the pretense of having a terminal illness, but then cleared for multiple, lengthy, out-of-state trips over the course of five years.  The government has agreed to accept $3,022,000 to resolve these allegations. There was no admission of liability.

Attorney Commentary - Hospice Compliance: When we represent Hospices we get them engaged in compliance in a step-by-step manner. In compliance plans and audits for hospices, we focus on areas including:
-- need to review the data for patients and monitor patients who have received more than six months of hospice care;
-- whether diagnoses were for terminally ill patients and how that is confirmed for admissions;
-- whether staff obtain any commissions for patients who stay longer or are recertified;
--  whether hospice is being provided to patients in assisted living facilities and any arrangements between the two facilities (which is another focus of investigation by OIG);
-- whether any incentives exist between referral services and hospice that could potentially violate STARK or Anti-Kickback statutes (federal and state);
-- the licensing of personnel and running regular background checks;
-- documentation standards and ensuring there is no backdating of records; and
-- numerous other categories in order to keep hospices compliant.

Hospices need compliance plans since Medicare WILL be conducting audits (even if it is just to run the data) and is aggressive in seeking repayment and pursuing civil damages in qui tam cases. The government will pursue criminal prosecutions if there is proof of criminal intent. Compliance need not be as costly as organizations believe and having a law firm handle it where there is attorney-client privilege while compliance is stepped up is a wise idea.

Posted by Tracy Green, Esq.


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