Continuous Home Care Fraud: When Crisis Care Becomes a Billing Target

Hospice continuous care fraud occurs when a healthcare provider knowingly bills Medicare for crisis care without the patient’s qualifying crisis, required nursing care or hours actually delivered. The nurse sees the patient. The scheduler knows who was assigned. The biller sees the hours sent to Medicare. When those accounts disagree, someone inside the hospice may know why the claim describes care the patient never needed or received. That connection between the bedside and the bill is where a hospice fraud case takes shape.

What Qualifies for Continuous Care in Hospice?

Continuous home care qualifies when a patient needs intensive care during a brief crisis to relieve acute medical symptoms and remain at home. Skilled nursing must be central to managing that crisis. The patient’s condition supplies the reason for the higher level of care. When billed nursing never arrives, the patient loses care and Medicare pays for it anyway.

The Department of Health and Human Services’ Office of Inspector General explains the distinction in its report on hospice care in assisted living facilities. Continuous home care manages a crisis at home. General inpatient care covers pain or symptoms that cannot be managed in another setting.

Home can include an assisted living residence. The facility’s staff and the hospice’s staff may both be present, making it especially important to identify who supplied the hospice care and what they did for the particular patient.

Eligibility for hospice and the need for crisis care are separate questions. For continuous care, the clinical account should connect the acute symptoms, the care needed to manage them and the time that care was supplied.

What Is the Minimum Number of Hours of Continuous Home Care?

At least eight hours of qualifying care must be supplied on the particular day to receive the continuous home care rate. The care must also meet the crisis and nursing requirements. Hospice continuous care billing fraud can involve inventing hours or assigning one nurse’s time to more than one patient to reach that minimum.

The Inspector General’s 2019 report on hospice deficiencies explains that Medicare pays an hourly rate based on the continuous care furnished that day. The daily continuous care rate is divided by 24 to establish the hourly rate. Payment then follows the qualifying hours supplied.

A staffing schedule records an assignment. Visit notes and time records account for the work. The Medicare claim assigns hours to the patient. We compare those accounts to understand how the hospice arrived at its bill.

What Nursing Percentage Does Hospice Continuous Care Require?

The nursing percentage for hospice continuous care must exceed 50% of the care hours. Registered nurses, licensed practical nurses and nurse practitioners provide the nursing component. Hospice aide and homemaker services can supplement it.

The Homestead Hospice complaint’s description of the Medicare standard makes the comparison explicit: the nursing share is measured by hours of care. A roster with a nurse’s name on it leaves the essential question open. How much of the patient’s care did that nurse actually provide?

Aide coverage and nursing coverage are different inputs to the bill. When we examine the staffing mix, we connect each person’s role to the service notes and the time assigned to that patient. A total labeled continuous care can conceal a different mix underneath it.

Hospice Continuous Care Scheduled Instead of Crisis Care

Scheduling continuous care to meet a billing target puts the staffing plan ahead of the patient’s condition. The question is why the patient was placed at that level: what acute symptoms required it, who assessed them and what instructions led to the claim.

A whistleblower’s complaint concerning Homestead Hospice alleged that the company sold hospital discharge planners on transitional care for patients leaving the hospital, then billed it as continuous care:

The same complaint alleged that, when the whistleblower called the office on a patient’s behalf, staff said the nurse could not leave until the billable minimum had been reached. In that account, the billing threshold was deciding how long the nurse stayed.

The sales promise, the schedule and the patient’s assessment answer different questions. A marketer knows what the family or discharge planner was offered. A nurse knows what symptoms required treatment. Management instructions can explain why the billed level followed the promise even when the assessment pointed elsewhere.

Why the Level of Care Is Worth So Much

The hours and the choice of level both affect the payment, which is why management’s targets matter alongside the clinical record.

In its 2012 Odyssey announcement, the Justice Department described continuous care as paying several hundred dollars a day more than routine services. Its 2015 St. Joseph announcement described the continuous care rate as nearly six times the routine daily rate.

The economics reach the bedside through ordinary business decisions: how services are marketed, who is scheduled and how many crisis-care days management expects staff to produce. A target for billed days can be traced back to the instructions given to the people assessing patients. That is the connection the civil cases make visible.

Continuous Home Care Fraud Cases

These health care fraud cases show recurring allegations of unnecessary crisis care, care that was never supplied and pressure to increase the days billed.

Odyssey and Unnecessary Continuous Care

Odyssey Healthcare agreed to a $25 million settlement in March 2012 over allegations that it billed Medicare for continuous home care that was unnecessary or failed Medicare’s requirements.

Former employees brought the qui tam cases. Their position inside the business mattered: the complaint describes patient assessments, supervision of nurses and review of records showing who supplied the care. The government’s announcement said the whistleblowers would receive more than $4.6 million from the resolution.

St. Joseph and Crisis Care Without a Crisis

St. Joseph Hospice and its majority owner agreed to pay $5,867,518 in September 2015 to resolve allegations of billing continuous care for patients who did not qualify. DOJ described the hospice as an outlier in its use of the benefit and said its investigation identified patients receiving the services without a crisis.

The announcement said the three former-employee whistleblowers would receive a little more than $1 million from the recovery.

The whistleblowers’ complaint alleged a commercial reason for that pattern. According to the complaint, St. Joseph marketed around-the-clock hospice care to hospitals as a way to discharge patients sooner, and to families as extra care without extra cost. The whistleblowers alleged that chart reviews identified patients billed for continuous care who were not in crisis. The marketing pitch and the bedside record were telling different stories.

VITAS and Targets for Crisis-Care Days

Chemed and VITAS agreed to a $75 million settlement announced in October 2017 covering allegations about both hospice eligibility and continuous home care. DOJ alleged that VITAS billed for crisis care that was unnecessary, not provided or did not meet Medicare requirements.

The department also alleged that the company set goals for the number of continuous care days billed and pressured staff through aggressive marketing practices. In the government’s account, a patient’s crisis had become a production target. The useful evidence includes the target, who communicated it and what happened to patient assessments and billing afterward.

Home Care Hospice and Fabricated Records

The July 2017 civil settlements concerning Home Care Hospice addressed allegations of unnecessary hospice services and crisis care that was unnecessary or never provided. DOJ alleged that false claims were supported by fabricated records.

Former employees had brought the case. Here the alleged problem reached the documents themselves: the paperwork purported to support services the government said patients did not need or receive.

What Assisted Living Billing Patterns Reveal

An unusual concentration of continuous care payments identifies a place to examine the patient-level records. The Inspector General’s January 2015 report, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities, found that one unnamed national for-profit chain received 64% of Medicare’s continuous home care payments in assisted living facilities during 2012. The same chain received 11% of routine home care payments in that setting.

In its response to the report, the Centers for Medicare & Medicaid Services supported considering hospices with a high proportion of patients receiving continuous care for further review. We take that inquiry into the crisis assessments, nursing notes and staff assignments. Those records explain what lies behind the billing concentration and who chose the level charged to Medicare.

When Hospice Continuous Care Hours and Payroll Do Not Match

When hospice continuous care hours and payroll do not match, we compare the patient, the employee, the date and the time billed. Payroll and timekeeping account for paid work. Nursing notes and assignments show which patient that work concerned. The claim shows what Medicare was asked to pay for.

An Odyssey whistleblower complaint describes the kind of overlap that makes this comparison useful:

The complaint described a nurse assigned to a continuous care patient while also assigned to another patient in a different wing of the same nursing home. It also alleged that records showed the same nurse recording care for different patients in the same hour. The patient assignments supplied a comparison that a single finished chart could hide.

A nurse can explain the care at the bedside. A scheduler can explain overlapping assignments. A billing or compliance employee can connect the claim to a management instruction or an earlier warning. Hospice whistleblowers bring that operational knowledge to a case.

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

When You Know Who Worked Those Hours

If you know how crisis-care targets became nursing assignments or Medicare claims, speak to one of our whistleblower experts about how those hours reached the bill. We build the case with you around the patient’s needs, the care delivered and the decisions behind the bill, and bring in hospice fraud whistleblower lawyers who understand clinical records and Medicare payment. You have a partner from the first conversation through the case.