Recent news post illustrates measures being taken to monitor hospice providers. The U.S. Attorney for the Northern District of Illinois on Jan. 27 accused Seth Gillman, an attorney and part owner of Passages Hospice LLC, of federal health care fraud, alleging the company billed Medicare for medically unnecessary inpatient care for hospice patients, kept patients in hospice care too long and doctored patient records before giving them to a CMS program safeguard contractor.
Link: HCF Google News Alert 13Feb2013
Whole article:
Featured Health Business Daily Story, Feb. 13, 2014
Hospice Exec Charged with Obstructing Audit, Billing for Unneeded Services
Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on Medicare compliance, Stark and other big-dollar issues of concern to health care compliance officers.
February 3, 2014
Passages deployed hospice nurses to care for patients in their homes and nursing homes in Chicago and other parts of Illinois. Along the way, Gillman allegedly “participated in a scheme to defraud Medicare” from August 2008 to January 2012, according to an affidavit filed in support of the criminal charges by HHS Inspector General Special Agent William Luczak. Some patients allegedly were not eligible for hospice care — their diagnoses included dementia and failure to thrive — or they were inappropriately admitted for inpatient care, often without a medical director’s approval, the affidavit contends. Gillman allegedly knew what was happening because of a 2009 internal audit, a review of patient files and a report by an outside consultant, according to the Department of Justice press release. When a Medicare auditor requested medical records, Passages feared an overpayment recoupment was in its future, which allegedly set in motion documentation changes to support the level of care billed, an activity overseen by the compliance officer.
“It’s tempting when you get a request for charts to make sure those charts look good. But it’s one thing to make sure the chart is complete and to find all the missing pieces, and it’s another thing to change medical records,” says former federal prosecutor Sheila Sawyer, with Waller Lansden in Nashville. That’s a common tipping point between civil and criminal allegations, she notes. There will always be imperfect or poor documentation — “every provider suffers from that to some extent,” she says. But providers cross a line that is virtually impossible to come back from “if they instruct staff to falsify charts and allegedly put false and affirmatively incorrect statements into the chart to justify care that is not warranted,” says Sawyer, who is not involved in the case.
Passages was first hit with a civil investigative demand in 2011. After investigators reviewed emails, patient files and other documents, they served a search warrant in 2012, indicating this morphed into a criminal case, Sawyer says. The affidavit claims that 30 former and current employees have been interviewed.
Medicare covers hospice for patients who are certified as terminally ill, which means they have a life expectancy of six months or less. Patients receive palliative, not curative, care for 90 days, and, if medically necessary, are recertified for 90 more days. Beyond that, they must be recertified as terminally ill every 60 days. Medicare pays a daily rate for hospice care at one of four levels: routine care, general inpatient care (GIP), continuous home care and inpatient respite care. GIP is intended only for short-term interventions (e.g., pain control) and pays far more than other types of hospice care. In 2012, for example, the daily rate was $151.23 for routine care and $671.84 for GIP.
The affidavit — which reflects the government’s use of data mining in enforcement actions — charts the growth in GIP admissions for Passages hospice patients and the associated Medicare reward. Between June 2006 and June 2008, Passages’ GIP patient days per month averaged seven — a monthly payment of $4,437. That rose to 619.3 days in 2009, which paid $397,997, and climbed to 1,430 GIP patient days per month in 2011, when GIP average monthly payments to Passages were $946,743.
Some Passages patients stayed for longer than the norm, according to the affidavit. Claims data for January 2006 to October 2011 show that about 22% of Passages patients were in hospice care for more than 180 days. The national average for hospice stays longer than 180 days was 11.8% in 2009 for members of the National Hospice and Palliative Care Organization (NHPCO), the affidavit alleges.
Diagnoses of Passages Patients Changed
The reason for hospice admission to Passages allegedly changed over time. While cancer-related diagnoses made up about 24% of admissions in 2006, that number dropped to 10% and then 12% in 2009 to 2011, compared to 40.1% for NHPCO members. At Passages, dementia diagnoses rose from 3% of admissions in 2006 to 50.1% in 2011, the affidavit alleges. The government hired a hospice physician to review 13 files and he determined nine of the patients were not eligible for the Medicare hospice benefit for part or all their services, the affidavit alleges.
A former Passages director of clinical services — referred to as “Individual B” in the affidavit — allegedly told federal agents she was “surprised” by the patient population when hired in early 2009. “In the course of an audit that she performed soon after being hired, Individual B found that 70-90% of the patient files did not have a diagnosis or proper documentation to make the patient eligible for the Medicare hospice benefit,” the affidavit alleged. She mentioned to Gillman one patient who had psychiatric issues, but could feed herself, talk and was not underweight or in pain. Individual B recommended the patient’s discharge, but Gillman allegedly told her to “keep your mouth shut and do what I tell you,” the affidavit says. Passages billed for four years of hospice services, the affidavit alleges. “During that time, Passages changed the lead diagnosis three times” on claims — from “unspecified psychosis” to “secondary diabetes mellitus with ketoacidosis uncontrolled” to “dementia with behavioral disturbances.”
Admissions for GIP Care Were a Problem
The affidavit also zeroes in on admissions to GIP, which generated $23 million for Passages. Some patients were allegedly admitted for skin tears, drug changes and other medically unnecessary reasons, the affidavit alleges. According to a former Passages clinical director — identified as “Individual E” — Gillman “said that if a patient was under Passages’ care, they were sick enough to warrant general inpatient care.”
Nursing directors allegedly sent forms to Gillman showing which patients were on GIP, and when. “None of the forms for November 2008 gave a reason for why the patients were on general inpatient care. Some of the forms from December 2008 and January 2009 gave reasons for GIP, but many were blank,” the affidavit alleges. At least one medical director raised concerns about the alleged failure to get a physician’s certification for GIP, and recommended changes to Passages’ procedures. That improved compliance in the medical director’s region, the affidavit says, but some Passages patients were still sent to GIP without a medical director’s signed order.
Around the fall of 2008, Gillman allegedly started paying bonuses to the directors overseeing nurses and certified nursing assistants based on their GIP volume, the affidavit alleges. Gillman also approved large bonuses for himself and Individual A “based on the number of patients per day at certain nursing home facilities in the Belleville Region,” with Gillman collecting $833,375 from March 2009 through April, the affidavit alleges.
The obstruction of a Medicare audit also is alleged by DOJ, with the alleged help of the Passages chief compliance officer at the time. In August 2009, TrustSolutions LLC, then a program safeguard contractor (PSC), requested 30 patient files. Nursing directors started changing some of the medical records, according to emails sent by the compliance officer to Gillman. The compliance officer wrote on Aug. 5, 2009, that regional directors “are assuming all of the pt. were on GIP and going in to ‘fix it’ to reflect that.” Almost two weeks later, the compliance officer emailed Gillman that “Yes, I stay up at nite and worry how we will get this done, and not have to pay them big $$$ back.”
Several Passages employees admitted they altered patient files, and TrustSolutions and law enforcement have different versions of medical records for one patient, the affidavit alleges.
After several weeks of allegedly doctoring records, Passages hired a consultant to review them. The consultant discovered many problems, even when records were prettied, the affidavit alleged. For example, almost half had levels of care that were not supported and Passages was using GIP improperly for patients who had infections. Interestingly, Passages allegedly used the consultant’s findings “to try making further alterations to the patient files,” the affidavit contends.
The allegations illustrate how much the government relies on data mining to identify outliers, Sawyer says. “We have hospice clients who pay a lot of attention to NHPCO data and are always checking to certify their statistics are in line with national averages and if they are not, they make sure there is an appropriate reason,” she says. If compliance officers at any organization find outliers or other indications of noncompliance, they should take it to the CEO. But make sure you have concrete examples of the problem, Sawyer advises. “People are really busy and stressed. If complaints are vague and not documented and they have no way to get their arms around a problem, it’s hard to deal with,” she says. “Be thoughtful in describing it. Don’t overstate or understate the issue.” If they suspect CEO involvement, compliance officers can head straight to the board.
Gillman appeared voluntarily before a federal magistrate judge, and was released on a $150,000 bond, the U.S. attorney’s office says. He has not yet entered a plea. Sawyer says the government can’t move forward unless Gillman is indicted by a grand jury within 30 days of the charges being filed. His lawyer did not return an RMC call requesting comment.
Read about the case at www.justice.gov/usao/iln.
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Replies
I read about this case before, and I am glad the government is being vigilant about it. Let this be a wake-up call to others committing Medicare fraud.