When a patient elects hospice care, he/she is choosing to receive care that will not cure their terminal illness, but should provide comfort and relief from pain. All services related to their terminal illness become the hospice’s responsibility. It appears, however, that hospices do not always provide the care patients need to control pain and manage symptoms, according to a report issued by the United States Department of Health and Human Services, Office of the Inspector General (OIG). On the contrary, the recently released report by OIG, the Medicare hospice program is rife with fraud and abuse, often denying beneficiaries of the program the care and comfort they deserve and expect.
The Medicare Hospice Program Report
The recently released report looked at vulnerabilities in the Medicare Hospice Program. Hospice care serves terminally ill beneficiaries who decide to forgo curative treatment for the terminal illness and instead receive palliative care. Hospice care aims to make the beneficiary as physically and emotionally comfortable as possible and allow the beneficiary to remain in his or her home environment. It is an interdisciplinary approach to treatment that includes, among other things, nursing care, medical social services (services based on the patient’s psychosocial assessment and the patient’s and family’s needs), hospice aide services, medical supplies, and physician services. The Hospice Program has grown significantly over the past decade as the older population in the U.S. continues to increase. In 2016, Medicare spent about $16.7 billion for hospice care for 1.4 million beneficiaries, up from $9.2 billion for fewer than one million beneficiaries in 2006.
Key Findings of the OIG Report
OIG found several systemic and/or widespread problems with the Medicare Hospice Program, including:
- Hospices do not always provide needed services to beneficiaries.
- Hospices sometimes provide poor quality care.
- In some cases, hospices were not able to manage effectively symptoms or medications, leaving beneficiaries in unnecessary pain for many days.
- Beneficiaries, their families, and caregivers do not receive crucial information to make informed decisions about their care.
- Inappropriate billing costs Medicare hundreds of millions of dollars, billing for an expensive level of care when the beneficiary does not need it.
- Fraud schemes in hospice care negatively affect beneficiaries and the program, such as:
- Enrolling beneficiaries who are not eligible for hospice care.
- Billing for services never provided.
- The current payment system creates incentives for hospices to minimize their services and seek beneficiaries who have uncomplicated needs.
Poor Quality Care
Hospices provided fewer services than outlined in the plans of care for 31 percent of claims for hospice beneficiaries residing in nursing facilities. In addition, hospices did not provide adequate nursing, physician, or medical social services in 9 percent of general inpatient care stays in 2012. By way of illustration, consider the following examples:
- An 89-year old beneficiary’s respiratory symptoms were uncontrolled for 14 days during a general inpatient care stay in which the hospice rarely changed his medication dosage. The beneficiary continued to experience respiratory distress and anxiety.
- A hospice billed Medicare for serving a 101-year old beneficiary with dementia. He had uncontrolled pain throughout his 16 days in general inpatient care. The hospice did not change his pain medication until the last day and did not provide him with the special mattress he needed for more than a week.
Fraud Schemes
The investigation uncovered a number of fraud schemes in hospice care that negatively affect beneficiaries, their families, and caregivers. Some fraud schemes involve paying recruiters to target beneficiaries who are not eligible for hospice care, while other schemes involve physicians falsely certifying beneficiaries. Beneficiaries are put at risk when they are enrolled in hospice care inappropriately, as Medicare hospice does not pay for curative treatment for a beneficiary’s terminal illness. For example:
- An owner of a Mississippi hospice used patient recruiters to solicit beneficiaries who were not eligible for hospice care. These patients were not even aware that they were enrolled in hospice care. The owner submitted fraudulent charges and received more than $1 million from Medicare. The owner was later excluded from the Medicare program.
- A Minnesota-based hospice chain agreed to pay $18 million to resolve allegations that it inappropriately billed Medicare for care provided to beneficiaries who were not eligible for hospice because they were not terminally ill. The hospice chain also allegedly discouraged physicians from discharging ineligible beneficiaries.
Lack of Information
Beneficiaries and their families and caregivers do not always get the information they need when they elect hospice care because hospices often provide incomplete or inaccurate information on election statements. In 35 percent of general inpatient care stays, hospices’ election statements lacked required information or had other vulnerabilities. Most commonly, these statements neglected to specify that the beneficiary was electing the Medicare hospice benefit as opposed to Medicaid hospice or some other insurance.
Improper Billing
Moreover, the report found evidence of improper billing within the Hospice Program, including improper payments ranging from $447,000 to $1.2 million for services not meeting Medicare requirements. Hospices billed for inappropriate levels of care, lacked required certifications of terminal illness, or did not have sufficient clinical documentation. Hospices also inappropriately billed for expensive levels of care that were not needed. In 2012, hospices billed one-third of general inpatient care stays inappropriately, costing Medicare $268 million. Specific examples include:
- A hospice in Puerto Rico billed for services after the beneficiary revoked the hospice election. The hospice received at least $453,558 in improper payments for services billed on behalf of this beneficiary and others that did not comply with Medicare requirements.
- A for-profit hospice in Mississippi inappropriately billed Medicare for a general inpatient care stay lasting over seven weeks for a beneficiary whose symptoms were under control. She needed assistance only with personal care, eating, and the administration of medication, yet the hospice was paid almost $30,000 for general inpatient care.
- A hospice in New York billed for 1 month of continuous home care for dates after the beneficiary’s death. The hospice improperly received at least $1,266,517 for hospice services billed on behalf of this beneficiary and others that did not comply with Medicare requirements
The Current Payment System Creates Negative Incentives
A hospice is paid for every day a beneficiary is in its care regardless of how many services it provides on a particular day. The financial incentives created by this payment system may cause hospices to seek out certain beneficiaries over others. Hospices may target beneficiaries who are likely to have long lengths of stay or fewer needs, beneficiaries who have certain diagnoses, or are in certain settings.
If you have concerns about the level of care you, or a loved one, are receiving through the Medicare Hospice program, contact the local Health Insurance Counseling and Advocacy Program (HICAP) at (800) 434-0222 .
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