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Nursing Home and Hospice Fraud

Nursing homes, also sometimes called skilled nursing facilities or long-term care facilities, care for people later in life when they are unable to care for themselves because of illness or disability On the other hand, hospice care refers to end-of-life care designed to offer terminally ill patients comfort and support in their final months of life.

Often paid for by Medicare or other government healthcare programs, nursing home and hospice care provides emotional support, dignity and pain management during difficult times. For many families, the decision to place a family member in such care is difficult.

Types of Nursing Home and Hospice Fraud

Nursing homes and hospice facilities – like all health care providers – are susceptible to health care fraud, including Medicare and Medicaid fraud. Often times, questionable billing practices and other misconduct by nursing homes and hospice care facilities violate the False Claims Act. Such fraud deprives the Medicare and Medicaid systems of much-needed funds, potentially making it more challenging for patients to get the medical support they need. Fraud committed by nursing homes and hospice facilities can take a number of forms, including the following:

  • Billing for Unqualified Patients

    The most common type of hospice fraud involves billing Medicare or Medicaid for patients who do not qualify for hospice care. In 2015, there were at least 60 such cases prosecuted across the country, and the numbers may be much higher. Between 2000 and 2012, hospice spending increased from $2.9 billion to $15.1 billion, coinciding with the rapid rise in for-profit hospices. Currently there are few rules governing the specific amount of support hospices need to provide to patients. There are few quality standards to meet, no minimum requirements for how often care is provided, and low barriers to getting into business. This can open the door to abuse.

  • Overbilling

    If a doctor or health care provider charges Medicare or Medicaid inflated prices for services or medications, or charges for services or medications that were not actually provided, the misconduct may give rise to a False Claims Act case.

  • Unneccessary Medical Procedures

    If a nursing home or hospice facility orders unnecessary medical procedures to be billed to Medicare or Medicaid, the False Claims Act may be implicated.

  • Kickbacks

    Health care laws restrict the financial relationships that nursing homes, hospice facilities, doctors, hospitals, and other health care providers can have with doctors who refer patients to them. If a nursing home makes improper kickbacks or offers financial incentives for the referral of Medicare or Medicaid patients, the False Claims Act comes into play. For instance, in 2014, Omnicare agreed to settle allegations that it solicited and received kickbacks from the drug manufacturer Amgen Inc. in return for implementing “therapeutic interchange” programs that were designed to switch Medicaid beneficiaries from a competitor drug to Amgen’s product Aranesp.

Nursing home and hospice fraud cases

The Claim Against Evercare Hospice and Palliative Care

In July 2016, Evercare Hospice and Palliative Care agreed to pay $18 million to resolve False Claims Act allegations against them. The two hospices were accused of billing Medicare for patients not qualified for hospice care. Nurses at the hospices were allegedly encouraged to not keep accurate records of patients, and doctors were discouraged from dismissing patients not qualified for hospice care.

The claim against Evercare Hospice and Palliative Care was filed because former employees of the hospices came forward with information and, through the False Claims Act, were able to file claims on behalf of the government. Under the qui tam provisions of the FCA, they will receive part of the recovery of the lawsuit.

Whistleblowers and Nursing Home and Hospice Fraud

In hospice fraud cases, whistleblowers are critically important. Without whistleblowers, many cases of fraud would remain uncovered. Employees are often the first to notice something is amiss, and their testimony can be critical in proving that fraud took place.

If you have a potential whistleblower case, coming forward can make a big difference in reducing fraudulent business practices, protecting patient health, and saving taxpayer dollars. Contact Goldberg Kohn today for a free, confidential consultation.

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