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The Government is Actively Investigating Allegations of Hospice Fraud

The government is actively investigating cases involving allegations of hospice fraud.

(August 29, 2012): Hospice fraud has been the subject of news report recently in the wake of several hospice fraud cases brought by whistleblowers and the Federal government. Don’t let your hospice make the news! As all hospice providers know, a Medicare beneficiary is only eligible for the hospice benefit when a physician certifies that if that patient’s terminal condition in its regular course, the patient is not expected to live longer than six months. In addition, there are a number of tests, including the FAST score, that can lend further support to a physician’s terminal diagnosis. In any regard, however, these things must be reasonable and well-documented.

While no one can predict the true course of an individual’s condition – someone could pass away tomorrow with no symptoms or live many years with extraordinary conditions and infirmities – continuous re-certification of an individual with an alleged terminal illness will raise Medicare contractor eyebrows and quickly dissolve a physician’s credibility for making such a determination. This is only exacerbated if a number of patients at a hospice have been receiving hospice benefits significantly longer than six months. Every time an individual comes up for re-certification past the six month window, the hospice and the certifying physician should be sure that they explain exactly why the patient’s diagnosis remains terminal.

I. Recent Hospice Fraud Cases:

Because of the sensitive nature of hospice care – patients are electing to give up curative treatment and instead receive palliative care –  and the potential for fraud, government investigators, including the Department of Health and Human Services (HHS) Office of Inspector General (OIG) and the Department of Justice (DOJ), have cracked down on hospice billing lately. A physician and hospice in Pennsylvania, for instance, were recently indicted on charges of violating the Anti-Kickback Statute (AKS). In other locations, from Kansas to California, Texas to Florida, hospice fraud has become a highly investigated practice, where OIG, DOJ, and Medicare contractors are alleging violations of AKS or fraudulent certification of terminal diagnosis.

II. What Can Hospice Providers Do?

Either way, hospice providers should take note of the recent uptick in enforcement. If you receive a letter from a Medicare contractor, such as a ZPIC, RAC, or MAC, or a request from OIG or DOJ, it is important that you contact a qualified health law attorney about your rights and obligations. Whether you end up in the Medicare appeals process or in discussions with OIG or DOJ, you should retain counsel who is experienced and knows the people and the procedure for these types of matters.

Healthcare LawyerRobert Liles represents clients nationwide in Medicare overpayment appeals and other actions taken by RACs and ZPICs, including suspensions and prepayment review. In addition, he counsels clients regarding OIG and CMS self-disclosure protocols, and works with clients and the government in negotiating settlements of administrative claims. Moreover, he assists doctors, hospitals, hospices, home health agencies, and other providers in implementing effective compliance plans. For a free consultation, call Robert today at 1 (800) 475-1906.

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