Hospice Patients Alliance: Consumer Advocates

Has Your Loved One Been Threatened
With Discharge or Under-Served?

Under-Served Patients
Suffer at the Hands of Fraudulent Hospices

Families of terminally ill loved ones commonly report that some hospices are not providing needed services. Whether it is needed home health aide visits, inadequate visits by the RN, refusal to ask the doctor for increased pain medications for uncontrolled pain, refusal to provide oxygen, or other problems, the problem remains the same: the patient is not getting what is needed to manage his or her symptoms. Hospice is all about providing comfort care, managing the symptoms.

So, when a hospice fails to manage the symptoms or meet the needs of the patient, the patient and family are confused and distressed. They ask, "what is hospice about if they don't meet my loved one's needs?" Yes, what is it about if the hospice doesn't meet the patient's needs? By these hospices actions, the only thing it is about is a business that takes money from the government and then does not provide needed services for the patients and families that have come to a hospice for help. Fortunately, not all hospices are perpetrating this form of fraud. And that is what it is, "fraud," plain and simple. Fraud is not only overbilling for services, but also, under-serving your loved one!

Why would a hospice not provide needed services? Money, money, and again, money. Those hospices that have integrity do not under-serve their dying patients. They make sure the patient's needs are met, to the best of their ability. If the patient has severe congestive heart failure and needs oxygen, the RN case manager will use the standing orders to order oxygen for the patient. If standing orders do not include oxygen, then the RN will contact the physician and get a doctor's order for oxygen. If the RN does not get oxygen for a patient who is severely short of breath, and oxygen would alleviate that distressing symptom, the RN is violating the standards of care and her responsibilities under her own nursing license.

Why would an RN refuse to order oxygen, when needed by a patient? Because hospice management has instructed her not to provide oxygen and to save money for the hospice. Why would a hospice not send out home health aides when they are needed? ... to save money. Why would a hospice reduce the frequency of nursing visits by the RN to less than what is needed by the patient? To save money. However, one thing to remember is that the hospice is collecting money from the government or private insurer (Medicare, Medicaid, or private insurance company) specifically for the purpose that the hospice provide the care needed to meet the patient's needs. Not providing the services needed is a form of fraud: the government or private insurer is not getting what they are paying for ... needed hospice services.

Threatened with Discharge
At the Time of Your Greatest Need?

Some families are reporting that hospices are telling them that they "have to" discharge their loved one from the hospice program because the patient hasn't died soon enough! Isn't this "adding insult to injury," so to speak? When patients truly have a terminal illness and the physician has certified the patient as having a terminal illness, then a hospice cannot discharge the patient when the going gets rough and care needs increase. Some hospices take the money while things are easy for the hospice, but discharge the patient when more visits or medications are required to control the symptoms.

Misleading Information provided to the Dying
And their Families by Hospice Staff and Managers

When hospice staff go along with management plans to underserve the dying patients and their families, these staff are betraying the trust given to them by the public. In order to under-serve the patients and families, rogue hospices have to convince patients and families that what the hospice is doing is "the law" or "normal." So, they misinform the public about the standards of care.

We receive numerous complaints from the public about how hospice staff and managers told them that "Medicare regulations do not allow us to provide ...." and then the families describe needed services which Medicare mandates that the hospice actually provide. The hospice had told the families the exact opposite of what the standards are! When hospice staff share incorrect information that management has instructed them to give to the patients and their families, they are violating their licenses to practice and the regulations governing hospice. In addition, when hospice staff lie about the standards in order to commit fraud on behalf of the hospice, they are accomplices to Medicare fraud and risk being indicted on criminal charges. They also may be excluded from working in a Medicare funded hospice or other facility again.

When hospice staff mislead the patients and families, the patients and families naturally become confused. When they learn they've been intentionally lied to by the hospice nurse, social worker and manager, they become extremely distressed and angry.

Ethical hospice administrators are also infuriated by rogue hospice administrators and staff who violate the patient's rights. The ethical hospice administrators and staff cooperate fully with government enforcement efforts to stop hospice fraud and deception. Ethical hospice staff and administrators are distressed by the violation of the rights of needy patients and also by the tarnished reputation these rogue hospices create for all hospices.

Ethical hospices have no trouble letting the government inspectors look at their records (during standard annual or bi-annual inspections) and speak with patients and families, because these hospices are doing a good job serving the dying and their families, and they know they have nothing to hide. Rogue hospices have much to hide, and they have to lie to cover up their fraudulent activities.

Hospices That Under-Serve Patients
Violate the Mission of Hospice

Under-serving patients in their hour of greatest need is the opposite of what hospice is all about. However, it is not so uncommon or unheard of. Rogue hospices go to great lengths to excuse themselves and deceive hospice patients and families. They direct their efforts at getting the families to worry about the hospice that "can't" provide this service or that service, for whatever reason, when the fact is, the standards of care require the hospice to provide those needed services.

The mission of hospice is to meet the needs of the patients and their families during the dying process (and provide bereavement counseling afterwards). Rogue hospices fail to provide needed care and support to the very patients they are licensed to serve. They may not under-serve every patient, but they under-serve many, thereby skimming money fraudulently from the government.

Rogue Hospices Blame Government
for the Hospice's Problems

Some hospice managers and staff are blaming government anti-fraud efforts as an excuse for wrongfully discharging patients. They mislead patients and families by saying that the patient has to die within six months or the hospice has to discharge the patient. They say that the hospice will "get in trouble with the government" if they keep the patient in hospice. This is absolutely false!

The regulations do not say that the patient "has to die within six months." The regulations state that the physician must certify that the patient may die within six months. This is a statistical probability. Most hospice patients do actually die within six months, but many terminally ill patients live longer than the standard "six month" period. If the patient has the terminal illness and the physician has certified the patient as having the terminal illness, then no hospice with integrity will abandon the patient at the time of his or her greatest need.

While government enforcement of the regulations is imperfect in some cases, hospices are not being shut down for caring for patients longer than six months. In some well-publicized cases, the government inspectors have questioned some hospices that have provided care longer than six months, even going so far as to order the hospice to pay back money paid for care beyond the six months. However, upon administrative appeal, the hospices (who cared for terminally ill patients beyond six months) have won and not been punished for legitimate care for the dying. The government is fighting to get what it is paying for...what the U.S. taxpayer is paying for.

The United States General Accounting Office estimates that billions of Medicare dollars are lost each year to waste, fraud and abuse (this includes all areas of health care, not just hospice). Of those billions of dollars wrongly taken by corrupt health care corporations, a significant portion is taken by rogue hospices that do not operate based upon the true mission of hospice. Of course, hospitals, nursing homes and other large facilities perpetrate the largest percentages of fraud in the health care industry, since hospice is a smaller segment of the health care industry.

In 1995, in order to combat rampant fraud in the health care industry, the U.S. government started a project called "Operation Restore Trust." From 1995 through 1997, the U.S. Operation Restore Trust project investigating health care fraud (in just five states) "contributed to the overall collection of $187 million in fines, recoveries, settlements, audit disallowances and civil monetary penalties owed to the federal government." (See the U.S. Administration on Aging - Anti-Fraud and Abuse Activities Fact Sheet on Operation Restore Trust).

In fact, the government can (and has) recovered millions of dollars from even one single hospice. But there are over 3,000 hospices in the U.S. The actual fraud committed in the hospice industry is many, many millions of dollars annually. And when the government discovers fraudulent schemes by hospices, they order the hospice to repay the money wrongly taken. They "settle" and have the hospice agree to comply with the standards in the future. It is not the practice of the government to shut down hospices, because the public needs those hospices to meet their needs. The government forces the rogue hospices to change their unlawful, criminal behavior and stop defrauding the U.S. government and its taxpayers.

Some businesses and their administrators have chosen to enter the hospice field simply because they think it is a good "business" opportunity to exploit while the Medicare (and other) moneys are flowing fast. Yes, there are hospice administrators getting rich at big "mega-hospices" with many branches (sometimes in more than one state) while dying patients are not receiving needed services!

Time magazine (along with other newspapers and magazines) has documented how some large managed care organization administrators had received salaries and benefits amounting to millions of dollars. Some of the largest hospice agency administrators are also paying themselves extremely large salary and benefits. These administrators basically control their Board of Directors who determine the administrators' salaries and benefits. Could anything be more abominable than exploiting the dying, the most vulnerable of all, in order to pay oneself millions of dollars? There would be no anti-fraud efforts by the government investigating hospices if there were not many hospices committing fraud amounting to many millions of dollars!

We know that these hospices are committing fraud, because the State and federal government receive numerous complaints about these tragic violations of the patients' needs. We also receive numerous complaints from families all over the nation about these hospices. The families are devastated, and the patients are suffering terribly because of the mistreatment by these rogue hospices. They feel betrayed by the very hospice (and their staff) that they came to in their hour of deepest need.

Although some hospices wish to complain loudly about government regulation, honest hospices do their best to provide care and do not truly have worries about the government. Those who are worrying are hospices that are committing fraud, and they complain the loudest, hoping to sway public opinion to influence government policy and allow them to commit fraud without government intervention.

One goal of government anti-fraud efforts in this regard, is to prevent hospices from signing on patients who are not terminal at all, collecting money without providing hospice services and defrauding the government. A form of hospice fraud is to sign on patients who are not terminal, provide little service and collect money just for signing up these non-terminal patients. If a patient is truly terminal, no hospice is going to get in trouble if a patient lives longer than six months.

Need for Families to Advocate
For Their Loved One's Needs

Families report all sorts of "lines" or excuses that hospice staff and even managers have told them why their loved one is being under-served or threatened with a wrongful discharge. If you care about your loved one, do not believe it! Remember that "the squeaky wheel gets the grease" and that with today's health care environment, you will have to stand up to this type of mistreatment and insist that your loved one get the care he needs to have symptoms under control and receive the care needed according to his condition. Your concern as a family member is to see to it that your loved one's needs are met during the dying process, that she or he is kept comfortable and that a death with dignity is achieved. You will need to be an advocate for your loved one, to make sure the hospice provides what is needed and mandated by the standards of care.

When a hospice fails to provide needed oxygen, services or manage symptoms well, they are in violation of the standards of care governing hospice. When a hospice threatens a patient with discharge, even though the patient is truly terminal and suffering, the hospice has seriously violated its reasons for existing and the most basic requirements of the hospice regulations. If you have spoken with the RN case manager and hospice director and still not gotten needed services for your loved one, then making a complaint to the State inspection agency and handing a copy to the hospice will often turn things around. You can make out your own complaint or use the complaint form provided at our website.

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