Genesis Healthcare: Creekside Hospice Inside a Broader Settlement

In the Genesis Healthcare Creekside settlement, Genesis agreed to pay $53,639,288 to resolve allegations involving ineligible hospice patients, inflated physician billing, unnecessary therapy and deficient nursing care. Creekside supplied the hospice fraud allegations within that broader resolution. The hospice story reaches inside the chart: management allegedly told employees to conceal improvements in patients’ health and make physician visits appear to have happened.

The Department of Justice announced the settlement on June 16, 2017, with the payment based on Genesis’s ability to pay. The agreement covered several acquired health care businesses.

What Creekside Hospice Was Accused of Billing

The Creekside hospice component covered alleged Medicare billing for patients who were not terminally ill and inappropriate billing for physician evaluation and management services. The settlement announcement places that conduct at Creekside’s Las Vegas, Nevada facility from April 1, 2010 through March 31, 2013.

The earlier lawsuit concerned both Medicare and Medicaid. In its November 25, 2014 announcement of the complaint, the Department of Justice alleged that management directed staff to enroll patients regardless of eligibility. Staff were sometimes told to change records after claims had already been submitted, making the files say the requirements had been met.

The government also alleged that management instructed employees to alter records to show personal physician visits that never occurred. Separately, the government alleged that the companies repeatedly used billing codes for the medical director’s services that paid more than the work justified. A visit invented in the chart and a real service billed at an inflated level put different false information behind the claim. The government contended that Creekside’s conduct cost Medicare and Medicaid tens of millions of taxpayer dollars.

How Do You Document Decline in Hospice Patients?

The clinical record needs to show the patient’s condition, including improvements that bear on the prognosis. At Creekside, the government alleged that management discouraged staff from recording known improvements so Medicare and Medicaid would continue paying. According to the announcement, the hospice called those entries “Chart Killers.”

That phrase captures the alleged business priority. An improvement belonged in the patient’s medical history. Management allegedly treated it as a threat to reimbursement. The same account alleged that Creekside management aggressively discouraged staff from allowing patients or their families to revoke hospice elections. That decision affected the care patients could receive: electing Medicare hospice meant giving up coverage for treatment aimed at curing their terminal illness. Patients’ treatment choices and taxpayers’ money were both at stake.

Medicare pays hospice for each enrolled day, whether or not staff visit that day. Care costs tend to be higher at admission and near death, with a less expensive stretch between them. Keeping a patient enrolled keeps daily payment coming.

The HHS Office of Inspector General put the payment incentive bluntly in a January 2015 study:

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

A patient can continue receiving hospice care when later certifications support continued eligibility. Medicare’s hospice eligibility standard is a prognosis of six months or less if the illness runs its normal course. At each later benefit period, the physician’s certification must still have clinical support, as Medicare’s hospice coverage manual explains.

That is why the alleged instructions to suppress improvement matter. The physician deciding whether a patient still qualifies needs the clinical picture. A chart edited to preserve payment can hide the very observations that should inform that decision.

Why Genesis Appears in the Creekside Settlement

Genesis acquired Skilled Healthcare Group, whose subsidiary Skilled Healthcare LLC operated Creekside, after the conduct covered by the settlement.

Genesis’s business extended across skilled nursing, assisted and senior living, and rehabilitation therapy. It also acquired Sun Healthcare Group in December 2012. The Department of Justice said the agreement resolved six federal lawsuits and investigations.

At Skilled Healthcare’s rehabilitation business, the government alleged unnecessary therapy and claims for more minutes than patients actually received. Those claims went to Medicare, TRICARE and Medicaid. It also alleged inflated Resource Utilization Group levels, the categories used to determine Medicare nursing-facility reimbursement during the period at issue.

The Sun Healthcare and SunDance allegations concerned outpatient therapy in Georgia billed to Medicare Part B that was medically unnecessary or unskilled. The nursing-care allegations concerned Skilled Healthcare LLC’s claims to Medicare and Medi-Cal for grossly substandard or worthless services, including insufficient nurse staffing to meet residents’ needs.

The shared corporate resolution contains different stories about the care behind the bill. For a Creekside insider, the questions concern terminal eligibility, patient records and physician services. For someone in the rehabilitation business, they concern the need for therapy and the minutes actually delivered.

What Evidence Is Needed to Prove Fraud?

For the Creekside allegations, the important connections run from the patient’s actual condition to the certification, the physician’s work, management’s instructions and the claim submitted for payment. Our whistleblower experts examine how those records fit together: what a clinician observed, what the chart later said, who directed the change and what the hospice billed.

The federal and Nevada governments joined cases brought under the False Claims Act and the Nevada False Claims Act by a Creekside clinical manager and a former clinical manager. Those roles put the alleged chart practices within the everyday work of people responsible for clinical care. A person who saw an instruction to remove evidence of improvement may explain something the final chart conceals.

A whistleblower complaint involving AseraCare alleged a similar mismatch between earlier records and later entries:

The connection to hospice billing fraud is the change between what happened and what the payment record says happened. In Creekside’s case, the government alleged that some changes came after billing. The timing of an instruction can explain why a later version of a chart tells a different story.

How Much Is a Whistleblower Case Worth?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In the Genesis resolution, the Department of Justice announced a $9.67 million reward shared by seven former employees.

The clinical, billing and management knowledge a hospice whistleblower brings gives a healthcare fraud case its substance.

You Saw What the Chart Left Out

If you saw clinical observations removed, physician visits invented or billing pushed beyond the care provided, speak with our hospice whistleblower experts. We work with you to build your strongest hospice whistleblower case around the patient records and decisions you know, bring in hospice fraud whistleblower lawyers who understand eligibility and physician billing, and stay beside you throughout the case.