Hospice of Citrus County: Long Stays and Unsupported Eligibility Records

In the Hospice of Citrus County settlement, the Lecanto, Florida provider agreed to pay $3,022,000 to resolve allegations that it billed Medicare and Medicaid for medically unnecessary and undocumented hospice care. For nurses, medical directors and billing staff, the case turns on a familiar question: does the patient’s chart explain why hospice keeps billing?

The Department of Justice announced the settlement on November 19, 2015. Its account of the hospice fraud allegations reached from the reason for admission to the support for continued coverage. The government said the company knowingly or recklessly failed to document a valid basis for starting or continuing hospice care for the patients it identified.

The Department of Health and Human Services Office of Inspector General and the Florida Attorney General’s Medicaid Fraud Control Unit investigated the case. The Office of Inspector General also lists a five-year corporate integrity agreement for Hospice of Citrus and The Nature Coast, effective November 4, 2015.

The Patient Files Behind the Long Stays

The government identified at least 52 patients whose hospice stays exceeded 1,000 days between June 1, 2009 and March 15, 2015. Its allegation concerned what supported those stays: the patient’s condition, the explanation for continued services and the practitioner information in the file.

The Justice Department’s account of the records described missing support for the length of services, files that omitted basic patient characteristics, and records that were unsigned or carried inconsistent practitioner information. Those defects reached the foundation of the claim. What condition justified the care? Who stood behind that assessment? What supported keeping the patient enrolled?

The patient examples made the allegation more concrete. According to the government, some patients entered hospice simply because their spouse was already receiving hospice care. The alleged admission decision followed the household relationship where it should have followed the patient’s condition.

The government also alleged that patients admitted under the pretense of terminal illness were cleared for repeated, lengthy trips out of state over five years. Terminal illness on the chart, long trips on the calendar.

These examples connect the paperwork to the person receiving care. The government questioned both why a patient entered hospice and why coverage continued. An insider who knew the patient, saw the admission decision or reviewed the later assessments could explain that connection in a way a billing total never could.

What Happens If a Hospice Patient Lives Longer Than 6 Months?

A patient can continue receiving hospice care beyond six months when the required recertifications support continued eligibility. Long-stay hospice eligibility turns on the clinical basis for the next period of care.

Medicare’s hospice coverage manual describes the standard as a life expectancy of six months or less if the illness runs its normal course. The benefit allows two periods of up to 90 days, followed by unlimited periods of up to 60 days, with recertification. Each period needs its own support.

The government challenged the documented basis for care at the start and afterward. The clinical account has to follow the patient through those periods.

The physician’s narrative must reflect the individual’s clinical circumstances. Standard language used for every patient cannot do that job. In a hospice eligibility fraud case, the useful connection is between what clinicians observed, what the certification said and what the hospice billed.

Why Continued Enrollment Matters to the Business

Medicare pays hospices for each enrolled day, including days when no visit occurs. The business therefore earns revenue from the duration of care, while its work and costs vary across the stay. Costs tend to be highest around admission and death, with lower costs between them.

The Office of Inspector General examined this incentive in its January 2015 report, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities. Among beneficiaries receiving hospice care in 2012, those cared for primarily in assisted living had a median stay of 98 days, more than twice the median for beneficiaries at home.

Its explanation of the incentive was direct:

The study helps explain the financial importance of continued enrollment, while the Citrus allegations concern the company’s own patient records. When unsupported care keeps generating daily claims, taxpayers keep paying for the same unresolved eligibility problem.

The Same Documentation Problem at Haven Hospice

Haven Hospice later resolved a similar allegation about long stays and unsupported eligibility. In its December 21, 2017 announcement, the Justice Department alleged that some patients’ hospice diagnoses changed after several years when they failed to decline under the original terminal diagnosis.

The government also described diagnoses supported only by inconsistent practitioner information and patients who showed no objective indications of decline. That comparison gives the Citrus documentation allegation its practical meaning. The clinical story in the file, the clinician behind it and the patient’s actual course all belong together.

These hospice fraud settlements show why someone who understands the chart can contribute more than a count of enrolled days. The valuable knowledge is what supported the decision to keep providing and billing for care.

What an Insider Can Bring to the Case

An insider’s knowledge can connect the admission decision, later certifications and the claims to the same patient. In Citrus, the alleged gaps included the patient’s basic characteristics, the practitioner information and the basis for continuing care. The people who worked with those records may know how the gaps arose and who accepted them.

We examine those connections with the person who saw them. A nurse may understand how the patient’s condition compared with the narrative. A medical director may know the basis for certification. Someone in intake or billing may understand how the admission and continued enrollment reached the claim. The question is how those accounts fit together, including what the hospice knew when it kept billing.

A whistleblower case under the False Claims Act can pay the whistleblower 15% to 30% of what the government recovers.

You Know the Patient Behind the Chart

If you saw admission decisions or continued hospice billing that the patient records could not support, speak to one of our whistleblower experts about the patients the hospice kept billing for. We work with you to build the case around that knowledge and bring in hospice fraud whistleblower lawyers who understand disputed eligibility and clinical records. You have a partner from the first conversation through the pursuit of a recovery.