Hospice Patients Alliance: Consumer Advocacy


HOSPICE FRAUD & SCAMS YOU MAY
ENCOUNTER: ? (HOW TO AVOID THEM)

There are numerous documented cases of fraud occurring in the hospice environment as well as in every other health care field: i.e. hospitals, nursing homes, home health care, HMO's, insurance, etc. Of course, if you only read the newspapers and watched TV you'd never know it at all. Hospice organizations routinely deny or minimize the significance of fraud in hospice, often stating that these are very rare exceptions and that most hospices provide excellent care. However, those of us who have worked directly in the hospice industry know from the inside that it is too easy for hospice administrators to set up situations that result in fraud.

Why Hospice Fraud is So Easy to Perpetrate

  • People generally trust their nurses and other health care workers. This is especially true when the nurse comes to care for the dying. People simply cannot imagine that the hospice itself will take advantage of the patient it is supposed to serve.

  • Hospices are often viewed as charitable, compassionate servants of the dying, when some of the hospices are actually ruthless businesses that are like wolves taking advantage of the sheep. News media are reluctant to report documented cases of hospice fraud, because the trend of the media is to promote hospice and the care of the dying. How can the media outlets, such as newspapers, TV and radio stations report on violations by local hospices when they have recently published articles promoting the very same hospices committing the fraud?

  • Hospice, because of its image as a compassionate service, attracts prominent business leaders in the local communities, and many of these prominent business leaders serve on the Board of Directors of the local hospices. The ol' boy network protects the hospice even if fraudulent practices are occurring. This network blocks news coverage, blocks action by local governments (even at the State government level) and effectively hushes up the serious abuses by hospices which are occurring.

  • As unbelievable as it may be, hospice administrators often DO NOT teach their staff the full and complete regulations governing hospice care! They often give their staff inaccurate ideas about the regulations, saying that whatever the hospice is doing is absolutely legal, when it is actually felony health care fraud!

  • Hospices manipulate their staff into situations where they cannot provide the care needed by the patient, due to intentionally created shortages of staff in key areas such as "Continuous Nursing Care" for patients in crisis in their own home. By not making the effort to actually hire adequate staff, the administration makes sure they cannot provide nursing services as needed in the home, and the patient is forced into the hospice facility, against his will!

  • Hospices get paid on a "per-diem basis" which means they get a set amount of money per patient signed on, for each day the patient is enrolled in the program, regardless of how many services or medications they provide. The system of payment financially rewards hospices which skimp on services and enroll more patients.

  • Hospice patients and families are in most cases completely isolated from other patients and families who might give them information which could protect them from fraud or inform them of their rights. In most cases, families are living at home completely immersed in the time-consuming and exhausting work of caring for their loved one.

  • When patients enroll in the hospice programs, the hospice admissions staff do not always provide full, informed consent. Since the patients and families are not fully informed of their rights, they do not know what services they are entitled to receive.

  • Patients and families are in crisis mode, grieving the imminent loss of the patient; they cannot muster the energy to fight the hospice's deception or exploitation, even if they do know that they're being taken advantage of.

  • There is so little time, in many cases, for the patient or family to resolve problems which the hospice may be causing, before the patient dies. So when a hospice under-serves the patient and family, it is out of the picture before anything can be corrected. Complaints from family members can fall on deaf ears at the hospice, and appeals to higher levels of management can result in patronizing insincere apologies from administrators who are paid to simply make the problem go away. What good does it do for the hospice to apologize after the patient has already died, or the family and patient have suffered tragically as a result of a rogue hospice's intentional wrongdoing?

  • Staff who cooperate with a hospice's plans for fraud are rewarded by promotions and given power within the organization. The hospice can give pay raises to those who go along with the policies, even though the policies violate the federal and state Standards of care for the industry.

  • Staff who complain about problems in the hospice are routinely harassed, intimidated and made to feel so uncomfortable that they resign, leaving behind them staff who are so afraid of speaking up that they keep quiet in order to save their jobs.

While some hospice staff and administrators may be shocked by the thought of such abuse occurring, their shock is only to be matched by their naivete'. Those hospice staff and administrators who have integrity cannot believe that anyone would conceivable take advantage of the dying. Sadly enough, many do.

Common Examples of Fraud & Scams in Hospice

While many patients, families, and staff will find it difficult to explain fraud in hospice, fraud does occur. Many staff are unaware of the fraud occurring in areas other than their own area of the hospice's various departments. However, many staff are aware of such abuses yet remain silent. Taking advantage of the dying is one of the most despicable crimes one can think of. Yet there are, unfortunately, unscrupulous executive level hospice administrators who have no qualms about violating regulations and patients' rights in order to cash in on the opportunity to personally make extremely large fortunes while skimping on services to the patients.

All areas of hospice care may be subject to fraud of some kind; there is no area of hospice care that can be ruled out as a possible area for fraud. What must be kept centrally in mind is that the hospice must provide the services needed to meet the actual care needs of the patient. The frequency of services and type of services is NOT determined by the hospice's apparent problems in staffing; the frequency and type of services is solely to be determined by your needs! The hospice is required to meet the needs of the patient and family. Some examples of hospice fraud are:

  • Hospices can reduce the frequency of home health aide visits to the patient, so the patient is visited less often than really needed.

  • Hospices can reduce the frequency of RN case manager visits to the patient by requiring the RN's to take on overly large caseloads or reducing the number of days each RN works per week. RN's may simply telephone to the patient or family to check on the patient's condition. A telephone call cannot substitute for an actual on-site physical assessment of the patient's condition by the RN.

  • Hospices can reduce the availability of RN's, home health aides, counselors, chaplains, bereavement staff, social workers and dietitians by consciously choosing to NOT hire adequate staff, or delay the replacement of staff who resign. Without adequate staff being hired by the hospice, these hospice staff will have overly large caseloads and will not be able to visit and serve the patients according to the actual needs of the patient.

  • Hospices sometimes use Licensed Practical Nurses (LPN's) or Home Health Aides to perform tasks which only Registered Nurses (RN's) may properly perform. They may use LPN's or Home Health Aides in roles which require an RN's supervision, but not actually provide adequate RN supervision.

  • Hospices can skimp on the medications given to the patient for pain! How? Probably every community has physicians who order inadequate or ineffective medications for pain control. Some medications for pain can be quite expensive. The hospice is legally obligated to make sure the patient gets the medications needed to control the pain and maintain patient comfort. When a physician does NOT order adequate pain medication, some hospices may refuse to intervene on behalf of the patient's comfort. They choose not to question the physician's orders and thereby leave the patient in pain, but the hospice saves money by so doing!

  • As cruel as it may seem, some hospices refuse to provide oxygen to patients who are short of breath or who need oxygen for other reasons. The staff tell the families it is not needed, even if the family make suggestions or inquire about it. The hospice saves money by not having to pay for the oxygen.

  • During a crisis, hospices can refuse to provide continuous around the clock nursing in the patient's own home (not a hospice facility) and tell the family and patient that the hospice doesn't have enough staff to provide care in the home. When the hospice tells the patient and family that there aren't adequate staff to provide care at home and thereby keep the patient at home, the patient is often manipulated against his or her will into the hospice facility, where the hospice will then collect fees for room and board, which it wouldn't receive if the patient were kept at home.

  • Even after manipulating a patient against his will into its own facility, the hospice can still bill Medicare, Medicaid or private insurance for the more highly reimbursed level of care, such as Continuous Nursing Care or Inpatient Level of Care. The Continuous Nursing Level of Care may be billed if the facility is licensed as a "home" and not as a nursing home or hospice inpatient facility.

  • Hospices can ask patients or families to privately pay out of their own pocket for services which already are being reimbursed, or will be reimbursed, by Medicare, Medicaid or private insurance companies. Because of the isolation of the hospice patient or family, the fraudulent billing to the patient or family may go undetected completely. If the patient is already dead and the family wants to put the whole matter behind them, who will report the additional billing to the Office of Inspector General? If the patient and family do not know what is being billed to Medicare, Medicaid or private insurance companies (and they do not know what the hospice is billing) they have no way of realizing that double-billing is occurring. If confirmation of reimbursement from Medicare, Medicaid, or insurance companies arrive in the home several months later, or even later than that, the family will often not even read the confirmation of billing or will not understand that double-billing has occurred.

  • Hospices can make fraudulent or otherwise illegal arrangements with nursing homes or hospitals for referrals. Kickbacks to the hospital or nursing home for referring patients to the hospice are illegal. Patients and families would have no way of knowing about such kickbacks.


What to Look For

Whatever your particular situation, if your loved one is NOT getting the services needed, if the hospice is trying to talk you into transferring your loved one to their facility against his or her will, if your loved one is NOT being kept comfortable, if there is inadequate staff and you are getting exhausted while caring for your loved one, you must demand that the hospice provide the services needed to meet the needs of the family and patient, whether living at home or in any facility. The law requires the hospice to meet the needs of the patient and the family!

What to Do

It is crucial that you read all the printed literature, documents and contracts you have with the hospice. These pamphlets, brochures, contracts and papers must (by law) inform you of your rights to the various services available through the hospice. Most patients and families do NOT read all this literature, and thereby they lose their greatest protection from exploitation...KNOWLEDGE OF THE REQUIRED SERVICES. Knowing what services are required to be provided will allow you to make informed decisions about the care your loved one receives. Knowing what services are required will help you protect your loved one from exploitation.

If you are not getting the services needed to meet the patient's and the family's needs, you need to speak with the RN case manager. If you get the runaround or sophisticated excuses, you must demand to speak with the hospice's Medical Director and Manager. If you still do not quickly get proper action to correct the problem, put a complaint in writing and send it to your State's Bureau of Health Systems (which is responsible to inspect the hospice) immediately and also give a copy to the hospice.

You may use the form provided on this website to make a complaint:
Click here for Complaint Form

You can count on the hospice to move quickly to correct the situation if you actually put a complaint in to the State. If you believe there is actual fraud occurring, do not hesitate to contact both the U.S. Office of Inspector General and your regional U.S. Attorney's office. They will investigate your case and may find confirmation of long-standing patterns of hospice fraud. For direct links to the OIG and U.S. Attorney's Office/Department of Justice, see the section within this website for "Links to Put in a Complaint about Hospice Fraud."

What the Inspector General Says About Hospice Fraud in Nursing Homes

Although hospices and hospice organizations will deny it, the United States Department of Health and Human Services - Office of Inspector General (OIG) has investigated and clearly documented many cases of fraud in hospice. Because of so many cases of hospice fraud occurring, in 1995, the OIG released its Fraud Alert Bulletin detailing types of hospice fraud that may occur when the patient is residing in a nursing home. This report is available directly from the OIG at: http://www.oig.hhs.gov/fraud/docs/alertsandbulletins/hospice2.pdf or you can see it online at our website.or you can see it in written form published in the Federal Register: November 2, 1995 (vo. 60, Number 212) which is available at any major public library in your area.

Sept, 2009 US DHHS, Office of Inspector General Report
on Hospice Care for Beneficiaries in Nursing Facilities

In September, 2009, the U.S. Dept of Human Services, Office of Inspector General ("OIG") released a report showing the continuing problem of fraud committed by hospice agencies, this time when nursing home residents are enrolled into hospice programs. The report, entitled, "Medicare Hospice Care For Beneficiaries in Nursing Facilities: Compliance With Medicare Coverage Requirements" provided stunning details of how poorly hospice agencies were performing in nursing home settings! Many of the patients who are enrolled into hospice, but reside in a nursing home, do not receive the full range of services that hospices are required to provide. See the OIG report (or see it mirrored at our own website). The OIG also issued a Memorandum Report which it sent to the US Centers for Medicare Services summarizing the findings in the September, 2009 report and suggesting that the report contained information about the services actually provided to residents in nursing homes, so they might consider adjusting the amounts paid to hospice agencies (with the implication that they should be paid for the services they actually provided rather than what they were supposed to provide and did not). We have mirrored this Memorandum at our website as well.




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