Hope Hospice in Florida: Years of Hospice, Weeks of Inpatient Billing

In the Hope Hospice Florida settlement, Hope agreed to pay $3.2 million over allegations that it billed for patients who were not terminally ill and for unnecessary general inpatient hospice care. The hospice fraud case began with a former Director of Hospice Care. It reached two decisions a clinical insider would recognize: whether a patient should remain in hospice, and whether the patient needed the higher level of care on the bill.

The Justice Department announced the settlement on July 8, 2020. It identified Hope as a subsidiary of Hope Healthcare, a nonprofit providing hospice, palliative care and other services for older people in Lee, Hendry and Glades Counties. The resolution covered Medicare, Medicaid and TRICARE claims.

The former director brought a qui tam case under the False Claims Act in the Middle District of Florida. The announcement said the former director, as the whistleblower, would receive 19% of the settlement proceeds. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

The Four-Year Hospice Stays

The government alleged that Hope billed Medicare for four or more years of hospice care for certain patients who were not terminally ill during at least part of their stays. That part of the settlement covered claims from July 1, 2012 through June 30, 2016.

The hospice eligibility fraud allegation turned on the patients’ condition during the care billed. What did the doctor know when signing for another period of hospice, and did the chart support it? The government alleged that Medicare paid for end-of-life care when these patients were not terminally ill. Taxpayers carried that bill.

The healthcare payment structure explains the financial stakes. Medicare pays for each enrolled hospice day, including days when staff make no visit. Costs tend to be highest around admission and death, with a less expensive stretch between them. Keeping a patient enrolled keeps the daily payment coming.

A national study by the Department of Health and Human Services’ Office of Inspector General, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities, found that hospice beneficiaries in assisted living had longer stays and generated higher Medicare payments than beneficiaries in other settings. Its explanation of the payment incentive was blunt:

The financial reason to keep someone enrolled and the medical reason for doing so are questions an insider can see from different sides of the same chart.

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

Continued hospice care requires recertification of the patient’s terminal illness. Medicare’s hospice coverage manual ties eligibility to a prognosis of six months or less if the illness runs its normal course and allows continuing benefit periods. The clinical account has to follow the patient as the condition changes. In Hope’s case, the government challenged periods when it alleged the patients were not terminally ill.

What Are the Criteria for a GIP Hospice?

General inpatient hospice care, commonly called GIP, is for pain control or symptom management that cannot be managed in another setting, such as the patient’s home. It is intended to be short-term and pays more than routine home care or inpatient respite care. The need for hospice and the need for this inpatient level of care require separate clinical support.

The government alleged that Hope knowingly billed Medicare, Medicaid and TRICARE for medically unnecessary GIP from January 1, 2011 through June 30, 2016. It identified certain patients for whom Hope billed more than two weeks of GIP. The alleged problem was the medical need for the care billed during those stays.

This is where hospice billing fraud can turn on the level selected for a day. Billing GIP when the patient needs routine home care asks the government to pay more than the care warrants. The clinical record has to explain the need for the higher level.

Caregiver relief has its own level, inpatient respite care. Continuous home care is provided at home during a patient crisis. Along with routine home care and GIP, these are the four levels reimbursed by Medicare, Medicaid and TRICARE. GIP pays for pain or symptoms that require care beyond what another setting can manage. For an insider, the distinction lives in the reason for the inpatient care, the patient’s response to treatment and the level that continued to appear on the claims.

When the Chart Follows the Billing Decision

An insider can connect what the patient needed with what the hospice instructed staff to record and what it billed. That connection makes the difference between a billing pattern and an account of how the decisions happened. Nurses see symptoms and treatment. Billers see the level and dates on the claim. Clinical and compliance staff can see what reached the people making the decisions.

A separate complaint against Agape Senior Community alleged how inpatient billing could drive the clinical description. The whistleblowers alleged that nurses were told to change data entered into the system until it produced a GIP-eligible diagnosis. Their account also described an instruction to keep the inpatient stay going:

In that allegation, keeping the patient in GIP became the objective and the diagnosis became the means. Someone who heard the instruction could explain why the chart changed. Someone seeing only the final claim would see the higher level of care. We work with insiders to connect those views, including whether the clinical account changed because the patient changed or because someone wanted the billing to continue.

Haven Hospice and the Diagnosis That Changed

Haven Hospice, the name used by North Central Florida Hospice in Gainesville, faced a separate Florida case over care for long-term patients. In its December 21, 2017 announcement, the Justice Department said Haven agreed to pay $5,085,024, based on its ability to pay. The resolution also included a Corporate Integrity Agreement.

The government alleged that many patients showed no objective indications of decline and that some had their hospice diagnoses changed after several years when they did not decline under the original diagnosis. That adds a concrete question to a long-stay review: what changed in the patient that supported changing the diagnosis? The patient history and the explanations inside the hospice matter together.

What Hope’s Corporate Integrity Agreement Added

Hope also agreed to a Corporate Integrity Agreement with the Office of Inspector General addressing compliance with federal health care program requirements, including proper billing and submission of reimbursement claims. The agreement carried a five-year term.

You Saw the Care Behind the Claim

If you saw recertifications, inpatient orders or billing decisions that departed from the patient’s condition, speak to one of our hospice whistleblower experts. We build your strongest hospice whistleblower case with you around the clinical facts and the decisions behind the claims. We bring in hospice fraud whistleblower lawyers who understand eligibility and inpatient billing, and stand with you throughout the case.