Crossroads Hospice: Dementia Eligibility and the $5.5 Million Settlement

Crossroads Hospice agreed to pay $5.5 million to resolve allegations of hospice eligibility fraud involving Medicare claims for dementia or Alzheimer’s patients who were not terminally ill for part of their stays. According to the government, the patients had received care for more than three years. For a healthcare worker who handled those admissions, nursing assessments or certifications, the important question is what supported the decision to keep billing.

What the Crossroads Hospice Settlement Covered

The Department of Justice announced the settlement on November 23, 2021. The settlement covered Crossroads Hospice and Carrefour Associates LLC.

The hospice fraud allegations concerned Medicare billing from January 1, 2012 through December 31, 2014. The government alleged that certain patients with dementia or Alzheimer’s disease were ineligible for hospice for at least part of their care.

Medicare and taxpayers bore the cost of care that, according to the government, these patients did not qualify for during part of their stays.

Does Alzheimer’s Qualify for Hospice?

Alzheimer’s patients can qualify for Medicare hospice care when their condition supports a physician’s prognosis of six months or less if the illness runs its normal course. Hospice provides palliative health care for the terminal illness. Patients generally give up Medicare coverage for treatment aimed at curing that illness when they elect hospice. The certification has to explain why this particular patient’s condition supports that prognosis.

The Medicare hospice manual directs the hospice medical director to consider the terminal diagnosis, other health conditions and current clinical information. That is where admission and recertification decisions become important to an insider: what did the clinical record show, and what account of that patient reached the physician?

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

Hospice coverage can continue through further benefit periods when the patient continues to qualify. Medicare provides two 90-day periods followed by an unlimited number of 60-day periods, with a certification required for each period.

The standard remains a medical forecast about the illness’s normal course. In examining a long stay, we connect each period of billing to the clinical information and judgment supporting it at the time.

Why Long Dementia Stays Attract Financial Interest

Long stays can produce daily revenue while requiring relatively little care. That incentive sits alongside a difficult clinical problem: predicting the course of dementia.

The Government Accountability Office’s 2019 report on Medicare hospice care explains that dementia can involve periods when a patient’s condition stabilizes or improves. Its unpredictable progression can lead to hospice enrollment earlier than appropriate. The report found that beneficiaries with noncancer diagnoses had longer stays on average, and that longer stays generally brought higher payments.

The payment incentive was already visible around the period covered by the Crossroads allegations. In a January 2015 study of hospice payments, the Department of Health and Human Services’ Office of Inspector General explained that hospices received a daily payment even on days without a visit:

The study’s assisted living findings put the payment beside the work. For routine home care in those facilities in 2012, hospices received an average of $1,091 per beneficiary per week and provided an average of 4.8 hours of visits.

Medicare later changed routine payment to a higher early rate and a lower later rate, effective in 2016. The underlying business incentive remains recognizable: an additional covered day brings additional revenue.

Who Determines Eligibility for Hospice?

A physician certifies terminal illness.

The certification requirements call for a physician’s narrative explaining the clinical findings. It must reflect the individual patient’s circumstances, based on the physician’s review of the medical record or examination. A generic explanation reused for everyone cannot do that job.

What the Patient Record Says About Continued Eligibility

Clinical observations can show whether the account used to support continued hospice care matches the patient staff actually saw. Separate hospice complaints make that connection concrete.

In its complaint against Vitas Hospice Services, the government alleged that a patient did not meet hospice eligibility criteria for debility, dementia or Alzheimer’s during the periods billed. It described the patient’s condition this way:

Those are observations staff could compare with the explanation for continued eligibility. They give an investigator something specific to examine beyond the length of the stay.

A whistleblower complaint involving Curo Health Services alleged a different problem with the certification itself. Operations directors allegedly allowed staff to use the medical director’s login and electronically sign certifications without the doctor seeing the patient or reviewing the medical record. The complaint also described a nurse questioning terminal eligibility after observing no decline, followed by a director’s instruction to increase documentation.

In the government’s Curo case, the allegations included failing to ensure that certifying physicians received or adequately considered complete and accurate information about patients’ conditions. The connection to the resulting Medicare claims runs through the information and the decisions inside the hospice.

For a nurse, clinical manager or biller, the useful account is specific: the condition observed, what went into the chart, what management directed and which claims followed. We examine those connections with the insider. That is how knowledge of the care becomes evidence about the billing.

The Crossroads Whistleblowers and Their Announced Share

Three former employees and a Tennessee home health physician brought the two qui tam cases behind the Crossroads settlement. The physician brought an outside clinical perspective, while the former employees knew the business from within.

The Justice Department announced a whistleblower reward of more than $1 million for the former employees. That was their share of the recovery.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Hospice whistleblowers can bring different parts of the same story: what happened at the bedside, what reached the physician and how the business kept Medicare payments coming.

You Saw the Patient Behind the Certification

If you know why a hospice kept a patient enrolled when the clinical record told a different story, speak to one of our whistleblower experts. We work with you to build your strongest hospice whistleblower case around those decisions, bring in hospice fraud whistleblower lawyers who understand dementia eligibility and Medicare billing, and stay beside you throughout the case.