MJHS Hospice: Crisis Care to Keep Nurses Busy

The MJHS Hospice settlement resolved higher-care billing allegations for $5.225 million after the government accused the provider of charging Medicare and Medicaid for levels of hospice care its patients did not need. The whistleblower alleged that continuous care served the organization’s revenue and staffing needs. For someone who knows the charts and nursing schedules, that is a recognizable question about who the higher level of care was really serving.

Metropolitan Jewish Health System Hospice and Palliative Care is a New York nonprofit providing hospice care to patients with terminal illnesses. The Justice Department announced the settlement on August 19, 2020. A whistleblower’s qui tam complaint brought this hospice fraud case to the government, and the United States and New York joined part of it.

The Higher Rate Had to Match the Patient’s Needs

MJHS’s settlement concerned the level of care billed for particular patients. The government alleged that the provider knowingly charged for continuous home care and general inpatient care when patients did not qualify for those higher levels.

Hospice billing fraud follows the payment structure. Medicare pays routine home care by the day, including days without a visit. Continuous home care pays by the hour during a crisis that requires care at home. General inpatient care pays a daily rate for pain or symptoms that cannot be managed in another setting. Taxpayers fund that higher rate to meet a patient’s needs, not to keep a provider’s staff busy.

Eligibility and recertification concern the prognosis. This settlement concerned claims for more intensive care.

What Qualifies for Continuous Care in Hospice?

Continuous home care addresses an acute crisis that requires skilled nursing to control symptoms and keep the patient at home. The government’s continuous-care allegations against MJHS covered 2011 through 2015 and involved Medicare and Medicaid patients.

The whistleblower’s amended complaint described a financial incentive an employee could see in the daily work. It alleged that MJHS billed approximately $910 a day for continuous care, compared with approximately $150 for routine hospice care. It then alleged why the company used the higher level:

The alleged reversal is the point. A patient’s crisis should determine the nursing assignment. In the complaint’s account, keeping licensed practical nurses occupied helped determine the care level. The staffing schedule becomes important because it can explain a decision that the patient’s symptoms cannot.

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

At least eight hours of qualifying care must be provided on the billed day under Medicare’s payment rules. Payment follows the hours actually delivered.

A shift schedule describes who was assigned. The care notes describe the symptoms, the services and the time spent providing them. The claim describes what the government was charged. In reviewing a case like this, we connect those accounts for the same patient and date.

The complaint’s staffing allegation makes that comparison especially useful. A full schedule can explain why employees were working. The clinical record has to explain why the patient required crisis care.

What Are the Criteria for a GIP Hospice?

General inpatient hospice care requires pain control or symptom management that cannot be provided in another setting. MJHS’s general-inpatient settlement allegations concerned Medicare claims in 2012. The whistleblower separately alleged in the amended complaint that patients stayed at that level for weeks without justification.

For a clinician or biller, the useful question is what required inpatient symptom management on each date charged.

The same mismatch appeared in Covenant Hospice’s 2015 settlement. The government alleged that Covenant billed general inpatient care when routine home care was appropriate and that its medical records did not support the higher level’s medical necessity. That parallel makes the question concrete: the bill can overstate the intensity of care even when the person is a hospice patient.

Federal and State Recoveries, With a Whistleblower Share

The MJHS settlement agreement divided the payment between $4.85 million to the United States and $375,000 to New York. The federal component covered Medicare and the federal Medicaid share. The state component covered New York’s Medicaid share.

The split also matters when describing the whistleblower’s reward. The agreement specified an 18% share of each government’s recovery.

Refusing a Corporate Integrity Agreement

MJHS agreed to the settlement payment but refused a Corporate Integrity Agreement. The Department of Health and Human Services’ inspector general recorded a ten-year period of Heightened Scrutiny and dated the refusal August 7, 2020.

The 2009 study Medicare Billing Risk Perceptions of Hospitals Operating Under Corporate Integrity Agreements, published in the Journal of Forensic & Investigative Accounting, compared hospital managers’ assessments of billing risks under corporate integrity agreements and voluntary compliance programs. Its finding on unnecessary services speaks directly to the kind of billing risk at issue here:

In a hospice care-level case, the practical question for an insider is how management responds when the clinical account and the billing account disagree.

What the Chart, Schedule and Claim Show Together

The MJHS allegations connect a higher rate, the use of nursing staff and the patient’s medical need. Each part becomes more useful when it can be connected to the others. A nurse may know why a shift was assigned. A biller may know which level went on the claim. A clinical reviewer may know that the notes did not support continuing it.

Our work with hospice whistleblowers starts with those connections. We examine how the patient record became a payment request and who directed the decisions along the way. In this case, the alleged reason for assigning continuous care is particularly revealing because it connects the higher bill to the provider’s own operating needs.

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

Your View of the Care and the Claim

If you saw crisis-care assignments driven by staffing needs or inpatient bills continuing without a clinical reason, speak to one of our whistleblower experts about what happened inside your hospice. We build your strongest health care fraud case with you, bring in healthcare fraud whistleblower lawyers who understand hospice billing, and stay beside you as the case develops.