Haven Hospice: When the Diagnosis Changed and the Billing Continued

In the Haven Hospice Florida settlement, the company agreed to pay $5,085,024 to resolve allegations that it knowingly billed Medicare and Medicaid for medically unnecessary and undocumented hospice care. A former Haven physician brought the case. This hospice fraud case reaches into decisions a clinician or billing employee would recognize: what justified admission, what the patient’s condition showed over time, and why the hospice kept billing.

The Department of Justice announced the settlement on December 21, 2017. The defendant was North Central Florida Hospice, Inc., doing business as Haven Hospice, headquartered in Gainesville.

Why the Long Stays Drew Attention

Since June 1, 2011, Haven had treated at least 63 patients whose stays exceeded three years, the government reported. Some had been in hospice for nearly six years. The Department of Justice alleged that Haven lacked documented support for admitting these patients or continuing their coverage.

The government said diagnoses lacked adequate support or rested on inconsistent information from practitioners. Many patients allegedly showed no objective indications of decline throughout their time in Haven’s care. A terminal diagnosis kept justifying taxpayer-funded care while the expected decline never appeared.

When the Diagnosis Changed

Some Haven patients allegedly received a different hospice diagnosis after several years without decline under the original terminal diagnosis. That sequence is the distinctive feature of this case: the diagnosis changed after the expected deterioration failed to appear.

The change creates a concrete question for the chart: what new clinical information justified a different terminal diagnosis? The original diagnosis, the observations made over the intervening years, and the later explanation belong in the same account.

Medicare requires the certifying physician’s narrative to reflect the individual patient’s clinical circumstances. For the third benefit period and later recertifications, it must explain why findings from the face-to-face encounter support the prognosis. That gives the clinical history a continuing job: supporting the next certification, not merely explaining the first admission.

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

A patient can continue receiving Medicare hospice care beyond six months when recertification supports continued eligibility. The prognosis remains six months or less if the illness runs its normal course, as Medicare’s hospice coverage manual explains.

The benefit provides two 90-day periods followed by unlimited 60-day periods, with certification required for each. The hospice physician reassesses eligibility as those periods continue. The medical support for that decision is central to hospice eligibility fraud allegations such as Haven’s.

Why Continued Enrollment Has Financial Value

Medicare pays hospice by the enrolled day, including days when no visit occurs. Care is typically most intensive at admission and near death, with fewer services in the middle of the stay. Keeping a patient enrolled can therefore extend the lower-cost portion while the daily payments continue.

The 2019 Milliman report Hospice Medicare Margins, commissioned by the National Partnership for Hospice Innovation, examined Medicare claims and hospice cost reports. Its analysis found a statistically significant association between higher net Medicare margins and a larger share of patients with stays over 365 days.

That financial incentive makes the clinical explanation consequential. Each recertification supports continued care and continued payment. In Haven’s case, the government alleged that the documentation failed to justify that continuation.

The Physician Behind the Whistleblower Case

A former Haven physician filed the qui tam case in the federal court for the Middle District of Florida. The settlement concluded that lawsuit, and the Department of Justice said the physician would receive a share of its proceeds.

The role matters because a physician can compare the clinical information supplied for certification with the prognosis the hospice asks the physician to support. In a case involving inconsistent practitioner information and changed diagnoses, that perspective can connect the medical explanation to the decisions inside the provider.

Other hospice fraud whistleblowers see different parts of the same health care billing process. Clinical staff see observations and chart changes. Compliance and finance employees may see warnings and continued billing. A case can draw its strength from how those accounts fit together.

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

The Settlement and Corporate Integrity Agreement

The government said it accepted the settlement amount based on Haven’s ability to pay.

Haven also entered a corporate integrity agreement with the Department of Health and Human Services’ Office of Inspector General. The OIG listing identifies it as a claims review agreement and describes a five-year duration.

What an Insider Can Connect

The useful account connects the patient’s clinical history to each certification, any diagnosis change, and the hospice claims that followed. Information supplied to the physician matters alongside the chart itself. Internal warnings and instructions can show how the business responded when someone questioned continued eligibility.

We work with healthcare insiders to connect what the chart said, what management knew, and what the hospice billed. That account can show how decisions inside the business kept a patient on service.

The Same Gap in Other Hospice Cases

Hospice of Citrus County faced a similar allegation in Florida. In its November 19, 2015 announcement, the government identified at least 52 patients with stays over 1,000 days and alleged that the hospice lacked documented support for admitting these patients or keeping them in hospice care.

A whistleblower’s complaint against SouthernCare described the same gap at the level of a single patient:

The complaint alleged repeated certifications resting on a diagnosis the medical records did not support. That is the recurring question these cases put to the hospice: what clinical information justified continuing to bill?

You Saw the Patient Behind the Diagnosis

If you saw a hospice diagnosis change while the patient’s condition stayed the same, talk with our whistleblower experts. We connect the clinical history to the billing decisions and bring in hospice fraud whistleblower lawyers who understand disputed eligibility. We stay beside you through the case, turning what you saw into the evidence for your strongest hospice whistleblower case.