Understanding Hospice Fraud and Why It Is So Detrimental to Late-Life Care

In order to fully grasp the seriousness of Medicare fraud, primarily that pertaining to hospice care, it’s important to discuss the entire purpose for hospice: to provide end-of-life care for those deemed to be terminal. Once a patient is considered qualified for hospice, Medicare no longer provides curative medical care which would ordinarily treat or heal their ailments; rather, they seek to grant comfort for those with less than six months to live by taking a more holistic approach – offering spiritual and emotional support as well as round-the-clock nursing care to make the patient as free of pain as possible before their passing.

Hospice fraud is exceptionally troublesome for this very reason. When providers bill Medicare for medically unnecessary services, they not only prevent those that need care from receiving it, but they oftentimes force those into hospice that could have been treated with conventional medical care – fueled entirely by greed. In the case of Evercare Hospice and Palliative Care (now known as OptumCare LLC), who paid $18 million in 2015 for violating the False Claims Act, evidence points to the fact that up to 44 percent of their hospice patients exceeded 180 days in care, which suggests that they may have been suffering from something other than a terminal illness, and if true medical care was sought, may have lived longer. In fact, many of their patients suffered from conditions such as dementia, non-terminal pulmonary problems, and other vague diagnoses such as “failure to thrive.”

In order to keep these patients in their care despite being ineligible for Medicare hospice benefits, Evercare offered substantial bonuses to their employees who falsified documents in order to increase patient intake, and in many cases, fired employees who tried to investigate. One of the two whistleblowers in the case, Lyssa Towl, was a former employee who reported that she was put on a “corrective action plan” when she scrutinized the company’s indiscretions, and was later terminated when she discharged patients who were not eligible to receive hospice care.

Towl and her co-relator, Terry Lee Fowler, brought forward twenty-one cases in which the facility billed Medicare for patients who did not fit the criteria for hospice eligibility; the majority of these cases billed for lengths of time exceeding Medicare’s outlined 180-day limit – some cases accruing up to three years of fraudulent claims. Though there are various other factors that may play a part in extended hospice stays, such gross overestimation of life expectancy in multiple instances made it abundantly clear that Evercare was employing devious tactics in their admittance of patients.

Under the qui tam statute of the False Claims Act, Towl and Fowler filed the cases on behalf of the US government and were each awarded with a portion of the recovered funds for the information and testimonies they supplied. Due to their diligence to uphold the moral responsibility that should be devoted to all healthcare facilities, millions of taxpayer dollars were returned to the government so that they may be allocated to those who truly need care. Unfortunately, this kind of fraudulent activity is rampant and often goes undetected without the assistance of relators; so much so, in fact, that the National Healthcare Anti-Fraud Association estimates a loss of $68 billion annually due to healthcare fraud alone.

Whistleblower Justice Network Can Help You

Whistleblower Justice Network advocates for those who bring forward information that exposes any scheme to defraud the United States healthcare system. By partnering with whistleblowers, we seek to bring those who take advantage of our elderly and most vulnerable to justice.

If you have meaningful information regarding hospice fraud that you believe is in violation of the False Claims Act, Whistleblower Justice Network can help. Working alongside world-class legal counsel, we will ensure you are protected to the fullest extent of the law and that you receive credit for the information you bring to the U.S. government. Partnering with whistleblowers is all we do. Visit us at www.whistleblowerjustice.net, or call us at 844-WJN-4ALL.