Creekside Hospice: When Improvement Threatened the Claim

The Creekside Hospice lawsuit over allegedly ineligible patients and altered records became part of Genesis Healthcare’s $53,639,288 settlement, which also covered rehabilitation therapy and nursing-home care. The government alleged that staff suppressed signs of improvement, changed charts after claims went in and made physician visits appear to have happened. For a clinician who saw the original notes, the important question is what happened between the bedside observation and the record used to get paid.

Creekside operated in Las Vegas, Nevada. Whistleblowers brought the hospice fraud case as a qui tam lawsuit, and the Department of Justice joined it with a complaint announced on November 25, 2014. Genesis resolved the allegations as Skilled Healthcare’s successor in 2017.

The Improvements Called Chart Killers

The government alleged that Creekside discouraged staff from recording known improvements because those facts could interfere with payment. Its announcement gave the practice a name:

The alleged instruction put the claim ahead of the patient. A clinical observation had become something to keep out of the chart because it might interrupt the money.

The government’s account also reached beyond what staff initially wrote. It alleged that Creekside directed employees to enroll patients regardless of eligibility, sometimes instructing them to change records after the hospice had submitted claims so that the requirements appeared to have been met. That sequence matters to an insider: the admission decision, the bill and the later edit are separate events. An earlier version of the chart can show what the company knew when it billed.

How Do You Document Decline in Hospice Patients?

Hospice documentation records the patient’s actual clinical condition and the findings supporting the physician’s prognosis. Under Medicare’s hospice benefit manual, eligibility rests on a life expectancy of six months or less if the illness runs its normal course. The physician’s certification narrative must reflect that patient’s circumstances and the medical information reviewed.

The narrative is where bedside observations become the explanation for eligibility. Medicare requires specific clinical findings and an individualized account, rather than standard language used for every patient. A direction to leave improvement out of that account reaches into the information the physician needs to make the decision.

That is the hospice eligibility fraud concern in Creekside’s alleged chart practices. The employee who recorded an improvement and the manager who wanted it removed may be looking at the same patient with different objectives. We examine the original assessment, the later wording and the instruction connecting them.

A similar instruction appears in the whistleblowers’ complaint against Agape Senior Community. It describes a nurse recording a patient who had been driving and shopping, then being told to change what she documented:

The parallel is the direction given to the person writing the note. In both accounts, the alleged pressure concerned which observations were allowed to survive into the medical record.

What Happens If a Hospice Patient Lives Longer Than Six Months?

A patient can continue receiving hospice care when recertification supports continued eligibility. Medicare provides two 90-day benefit periods followed by an unlimited number of 60-day periods, with a new certification for each period.

That makes the ongoing clinical record important. The physician needs current information to support the next certification. The Creekside allegation was that management interfered with that information by discouraging staff from recording improvement. The inquiry follows what the patient showed, what the chart said and who directed the difference.

The economics of retaining patients also bear on the alleged suppression of improvement. In its January 2015 report, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities, the HHS Office of Inspector General found that hospice patients in assisted living received care for longer and generated higher Medicare payments than patients in other settings. The report explained the incentive under the payment system it studied:

That national study explains why retaining an enrolled patient could matter to a hospice’s finances. Creekside’s alleged conduct supplies the case-specific question: whether the business kept claims payable by changing the account of the patient’s condition and care.

Is Knowingly Billing for Services Not Provided an Example of Fraud?

Yes. Knowingly billing for services that were never provided is hospice billing fraud. At Creekside, the government alleged that management instructed employees to alter records so that doctors appeared to have visited patients when those visits had never occurred, to secure Medicare and Medicaid reimbursement.

The payment model helps explain why the particular record matters. For routine home care, Medicare pays a hospice a daily rate for an eligible enrolled patient, including days without a staff visit. The patient’s plan of care determines the services to be furnished. In Creekside’s case, the government alleged an invented physician encounter, and the later settlement specifically included inappropriate billing for physician evaluation and management services.

What Is the Difference Between Hospice Discharge and Revocation?

Revocation is the patient’s or representative’s choice to end the hospice election. Discharge is the hospice ending care, including when a patient’s condition improves enough that the hospice can no longer certify terminal illness.

The government alleged that Creekside management aggressively discouraged staff from permitting patients or families to revoke their elections. Alongside the alleged suppression of improvement, that describes pressure at another point where an enrollment could end.

We connect what a patient or clinician wanted to what management allowed and which claims followed. The chart tells one part of the story. The decision about keeping the patient enrolled tells another.

What Clinical Managers Could See

The Creekside whistleblowers included two clinical managers. Their roles put clinical work and management decisions in the same field of view. A bedside note can show the patient’s condition. A manager may also know who asked for a revision, what information reached the physician and how concerns were handled.

For hospice whistleblowers, those connections give the documents their meaning. We trace chart revisions and the information that reached the physician back to the people directing the work.

A clinical objection can also show how management responded when someone questioned the record. We connect that response to the claims that followed.

The Genesis Settlement Included More Than Creekside

Genesis resolved the Creekside allegations as part of a broader settlement announced on June 16, 2017. The Department of Justice identified the hospice conduct period as April 1, 2010 through March 31, 2013. It said Genesis acquired Skilled Healthcare Group after the conduct at issue.

The wider health care settlement also covered allegations of unnecessary or inflated rehabilitation therapy and grossly substandard nursing-home care. Those other businesses and services explain the size of the overall settlement. A later court opinion identified $10.8 million as the allocation resolving the hospice case.

DOJ also announced a combined $9.67 million reward for the whistleblowers across the resolved cases. That award covered whistleblowers from the acquired businesses together.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In a case about chart changes, an insider’s account can connect the patient information to the instructions and claims that followed.

You Saw the Record Before It Changed

If you were told to remove an improvement, rewrite a visit or keep a patient enrolled against the clinical team’s judgment, talk with our whistleblower experts about what happened. We build the case around your knowledge of the patients and the decisions, and bring in hospice fraud whistleblower lawyers who understand clinical documentation and Medicare billing. We stay with you through the case, making sure the original observations and the instructions to change them remain at its center.