Alexian Brothers PACE Enrollment Suspension: Selection Findings and Certification Ending

The Centers for Medicare & Medicaid Services and Missouri suspended enrollment in Alexian Brothers PACE after finding failures to provide necessary care and practices discouraging applicants with substantial future medical needs. The action covered Alexian Brothers Community Services in St. Louis, contract H2609. Missouri later reported that its PACE certification ended effective May 1, 2016 and participants moved to other assistance. For someone who worked in intake, care delivery or compliance, the story runs from the application to the medical record and the account given to regulators.

This page follows the earlier care failures, the selection findings and the certification ending for that St. Louis program. The notice identified Ascension Health as its parent. The separate question of false enrollment and capitation follows inaccurate eligibility or election information into a paid month. Here, the distinctive finding concerned people discouraged from getting in.

What Happened Before the Alexian Enrollment Suspension?

The Centers for Medicare & Medicaid Services imposed a $25,000 civil money penalty in its August 1, 2013 notice, citing substantial failures to provide medically necessary PACE services. The agency and state regulators had already conducted three monitoring visits or audits. The agency identified failures to assess medical needs, put appropriate care plans into practice and maintain a single comprehensive medical record for each participant.

The Program of All-Inclusive Care for the Elderly combines Medicare and Medicaid services to help people receive health care in the community. As the agency explained in that notice, the organization must build a written plan around each participant’s medical, health and social needs. Its interdisciplinary team assesses the participant, reassesses changing needs and coordinates care. Team members are responsible for sharing changes in a participant’s condition and documenting them in the medical record.

The findings showed what happened when that chain broke. Auditors found participants with diabetes who had missed required blood sugar monitoring or urine testing, and participants with asthma or chronic obstructive pulmonary disease who had not received lung-function or blood-oxygen tests. In one instance, a participant lost 25 pounds in three weeks without a primary-care physician’s assessment for proper treatment. The agency said the care failed to meet both national standards and Alexian’s own documented treatment protocol.

The care plans and records failed alongside the monitoring. The Centers for Medicare & Medicaid Services found that care was not appropriately managed or coordinated, putting participants at risk of serious deterioration. Records were incomplete and scattered across locations, with physician orders and laboratory results missing. The notice also said a former employee had disabled sections of the electronic record.

An insider who knows where an order or test result went can explain a break that the final chart alone may conceal. In the agency’s account, even the chart was in pieces.

What Did CMS and Missouri Find at Alexian?

CMS’s Kansas City Regional Office and the Missouri Department of Social Services found failures spanning care delivery, medical records, grievances, appeals and enrollment processing in their audit. The resulting notice connected those failures to delayed or denied medically necessary care and inappropriate handling of applications. It described problems in the decisions themselves and in the records that should have explained them.

The cancellation of medical orders was especially revealing. The notice described how a failure to authenticate medical-record entries could interrupt care:

That finding gives a clinician or records employee a concrete discrepancy to explain. The prescribing physician’s order said care was needed, while the cancellation could remove it without recording who authorized the change or why. The order changed. The explanation was missing.

The agencies also found that Alexian did not resolve grievances through the appropriate procedures or consistently give participants written information about that process. Participants and family members did not consistently receive written information about appeals either. For a worker who heard a complaint or saw a service denied, the correspondence and response records can show what the organization was told and how it answered.

The notice also identified failures to submit required reports of unusual occurrences and to investigate and analyze those incidents when they became known. That brings management’s response into the story: a care problem, notice of the problem and the account sent to oversight agencies are different records. The audit findings give a compliance worker specific decisions to recognize, including whether an incident reached the reporting process at all.

How Alexian Discouraged Applicants With Substantial Medical Needs

The federal and state agencies found that Alexian engaged in practices reasonably expected to deny or discourage enrollment by Medicare or Medicaid beneficiaries likely to need substantial future medical services. Their notice identified the operational failures behind that finding: missing level-of-care assessments, missing appeal information after enrollment denials, failures to refer applicants to alternative services where appropriate, and missing documentation of enrollment approvals and denials.

The payment structure explains why selection matters. PACE receives prospective monthly Medicare capitation for entitled participants and a separate negotiated monthly Medicaid payment for Medicaid participants. Those payments finance an integrated care obligation, including the services the interdisciplinary team determines are necessary. In the agencies’ findings, people likely to need substantial care were denied or discouraged from enrolling. We see a program working against the people it was built to serve.

For an enrollment worker, the revealing comparison is between the applicant’s documented needs and the reason the organization recorded for its decision. The Alexian notice specifically tied its processing failures to people with significant medical needs being denied or discouraged from enrollment. An assessment, an approval or denial, the information sent to the applicant and the explanation sent to regulators can show different parts of that decision.

What Happened After the Alexian Brothers PACE Suspension?

Missouri reported the end of Alexian’s PACE provider certification and the movement of participants to other assistance. The Family Support Division’s July 6, 2016 memorandum said all PACE cases had been reviewed and moved, and directed staff to authorize no new PACE approvals until a new provider was announced. For a worker involved in the transfer, those reviewed cases and replacement-assistance decisions connect the provider’s exit to what happened to its participants.

The suspension notice required the chief executive or most senior official to attest that the deficiencies had been corrected and were unlikely to recur. For a compliance worker, that required statement puts management’s account beside the care the team actually delivered.

Which Records Connect Care Failures to Government Payment?

Care, enrollment and finance records tell different parts of the government-payment story, and we connect them with the insider who knows what happened. We look at the assessment and care plan beside the orders, cancellations and documented services, then connect that account to the program’s government funding. Our PACE evidence page follows those connections from service requests to paid months.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. If you are considering reporting PACE program fraud, our work starts with what you saw and the account the organization gave about it.

You Know Why the Record Changed

Speak to one of our Whistleblower Experts about why an applicant was discouraged or a medical order disappeared. We bring in healthcare fraud whistleblower lawyers who understand capitation and care obligations, and stay beside you to build your strongest PACE whistleblower case around the decisions you can explain.