Guardian Hospice of Georgia: Recruitment Targets and the $3 Million Settlement

In the Guardian Hospice of Georgia settlement, the company agreed to pay $3 million to resolve allegations of Medicare hospice eligibility fraud involving patients it knew were not terminally ill. Two former case managers brought the case. Their complaint described nurses documenting the patients they saw while managers who had never seen those patients wrote the summaries used to keep them eligible. For an insider, the question runs straight through the chart: whose account of the patient reached the physician, and whose account reached the bill?

The Department of Justice announced the settlement on October 2, 2015. Guardian operated a for-profit hospice serving Atlanta. The former employees brought this hospice fraud case under the False Claims Act’s qui tam provisions in the Northern District of Georgia.

What the Guardian Hospice Settlement Was About

The government alleged that aggressive recruitment and enrollment targets, inadequate eligibility training for staff and medical directors, and failures to oversee the Atlanta hospice contributed to false Medicare claims. The allegations covered conduct from 2009 through 2012.

The complaint made the pressure concrete. The whistleblowers alleged that when they raised discharging ineligible patients at team meetings, a manager said Guardian needed to keep its patient census high. They also alleged that management ignored nurses’ notes, patient records and lab work when preparing admission and recertification documents.

That puts the medical director’s information at the center of the story. Elsewhere, hospice referral kickbacks have concerned what a physician received for referrals. In Tapestry Hospice’s case, the Justice Department alleged that medical directors’ compensation rose and fell with referrals. Guardian’s settlement announcement focused on eligibility training, recruitment targets and oversight.

What Makes Someone Ineligible for Hospice?

A patient who lacks a terminal prognosis of six months or less if the illness runs its normal course does not meet Medicare’s requirement for terminal illness. The clinical information supporting that prognosis is central to certification and continued eligibility.

The choice also changes the patient’s health care coverage. Electing hospice generally waives Medicare payment outside hospice for treatment of the terminal illness and related conditions. That gives a false admission consequences beyond the bill: a patient can lose access to other Medicare coverage for the illness while the hospice collects.

One example in the complaint brought that problem down to a single admission. The whistleblowers alleged that a patient’s wife called requesting hospice, without a physician referral, and Guardian fabricated a qualifying diagnosis. In their account, the request came first and the medical justification followed.

How Recruitment Targets Reached the Eligibility File

Medicare pays hospice for enrolled days, including days without a visit. An admissions target therefore has a direct financial purpose, and keeping a patient enrolled keeps that daily revenue coming. Care costs tend to be higher at admission and near death, leaving the middle of a long stay less expensive to serve.

The HHS Office of Inspector General examined that incentive in its 2015 report, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities. Analyzing Medicare hospice claims from 2007 through 2012, it found that in 2012 hospices typically provided fewer than five hours of visits a week to beneficiaries in assisted living receiving routine home care and received about $1,100 weekly per beneficiary. Its explanation of the payment incentive was blunt:

At Guardian, the whistleblowers alleged how management turned patient information into eligibility support. The hospice held weekly interdisciplinary team meetings to discuss patients’ health, care plans and eligibility. The complaint describes who controlled the summaries:

The whistleblowers said the result was a mismatch between the treating nurses’ observations and the summaries and recertification documents management wrote. The paperwork allegedly changed the patient on paper while the patient’s actual condition stayed in the nurses’ notes.

A similar pressure appeared at Good Shepherd Hospice, where the Justice Department alleged admissions and census targets alongside bonuses based on enrollment for marketers, admissions nurses and executive directors. The recurring issue is how a business target reaches the people responsible for deciding whether a patient belongs in hospice.

The Georgia Files and the Missing Eligibility Support

The complaint described an internal review of 17 Georgia patient files after Medicare contractor Palmetto GBA requested documents supporting claims. One whistleblower worked on the response team. According to the complaint, 14 files lacked a signed Election of Benefits form and 11 lacked documentation of a physician’s or nurse practitioner’s face-to-face evaluation. The review also found missing admission or recertification support and inadequate physician narratives.

The alleged response reached back into the files. The whistleblowers alleged that Guardian asked physicians to rewrite earlier recertification statements and demanded more from nurses:

Those requests concerned claims Guardian had already submitted to Medicare. The alleged instruction was to manufacture support for an earlier bill.

How Often Do Hospice Patients Need to Be Recertified?

Medicare requires certification for each benefit period: two initial 90-day periods followed by successive 60-day periods. The physician’s decision must have clinical support each time. Beginning with the third benefit period, a hospice physician or nurse practitioner must conduct a face-to-face encounter to inform recertification.

That repeated review made the alleged warnings consequential. Both whistleblowers said they warned a Georgia medical director that the information and documents were fabricated, yet he continued admitting and recertifying patients using the information supplied. Their allegation connects what the physician received with what he had been told about its reliability.

The Instruction to Change a Revocation Date

The whistleblowers alleged that a manager instructed a case manager to change a patient’s revocation date so Guardian could bill for the entire day. The case manager refused.

This brings hospice billing fraud down to a date in a patient’s file. It gives billing staff another view of the same financial pressure that the case managers described at admission and recertification.

What an Insider Can See in the Records

The Guardian complaint connects management instructions, nurses’ observations, physician certifications, document requests and Medicare claims. A nurse may know why a summary conflicts with the patient they treated. A biller may recognize the period a later rewrite was meant to support. A healthcare compliance employee may know who heard the warning and what happened afterward.

The two case managers who brought this case became hospice fraud whistleblowers through that view inside the operation. The Justice Department also announced that they would share in the recovery. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Saw What the Summary Left Out

If you saw recruitment targets turn into invented diagnoses, rewritten summaries or demands to backdate records, tell our whistleblower experts what happened inside your hospice. We build the case with you, connect the clinical facts to the Medicare claims, and bring in hospice fraud whistleblower lawyers who understand eligibility and billing disputes. We stay beside you as your partners throughout the case.