US Justice Department’s Spotlight on Hospice Sends ‘Powerful Message’ to Fraudulent Operators
The U.S. Department of Justice (DOJ) is prioritizing hospice as the agency cracks down on health care fraud. Increased reimbursement oversight could be on the horizon, lending to a potential rise in whistleblower cases.
DOJ counts hospice claims among the root causes of rising Medicare costs in recent years, according to Lisa Miller, deputy assistant attorney general overseeing the department’s Crime Fraud Section.
This is among the reasons that hospice fraud is among the top priorities for the regulatory agency, Miller indicated during the American Bar Association’s 33rd Annual National Institute on Health Care Fraud.
“The Health Care Fraud Unit and its partners are prioritizing the investigation and prosecution of schemes that affect vulnerable populations, including, but by no means limited to, sober homes fraud, illegal prescribing of controlled substances and hospice fraud,” Miller said. “In recent years, data has shown an increase in costs to the Medicare program resulting from claims for hospice care.”
The state of hospice fraud
Fraudulent or inaccurate Medicare claims cost the federal government an estimated $60 billion annually, according to a 2018 CNBC report. Medicare hospice claims represent a solid chunk, according to regulators.
For instance, roughly one-third (31%) of general inpatient hospice stays in 2012 were billed inappropriately, a $268 million cost to Medicare, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) reported.
The OIG pulled data from a sample of inpatient claims that year to determine that total. Roughly 20% of these inappropriately billed claims were patients who did not require inpatient care at all during their stay, while 1% held “no evidence that [a] beneficiary elected hospice or had terminal illness,” the OIG indicated in the report.
Regulators often consider factors such as patient eligibility questions, live discharges and longer lengths of stay to be red flags.
Fraud occurs across the care continuum, and it can have significant financial and societal impacts, according to Miller.
“Every day, fraudsters intent on lining their own pockets at the expense of the American taxpayer, patients, and private insurers abuse our nation’s health care systems. This drives up costs of health care for us all,” Miller stated. “It imperils the long-term solvency of Medicare and Medicaid, upon which millions of Americans depend. And any time greed replaces medical necessity as a factor in providing health care services, our communities suffer. We stop ongoing schemes in their tracks to minimize patient harm and financial losses, and to send a powerful deterrent message.”
Federal and state regulators and law enforcement agencies have been cracking down on suspected hospice fraud schemes across the country in recent years. In addition to hefty fines or settlements, some hospice leaders have faced criminal charges and prison sentences for their roles in fraudulent billing practices.
A case in point involves home health and hospice provider Merida Group. Last year federal prosecutors filed charges in the U.S. District Court for the Southern District of Texas against Merida Group Owner Rodney Mesquais and CEO Henry McInnis. The criminal complaints allege...click here to read the full article.
Greg Schneider
HCF Creator
HVA Founder & President
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