Serenity Hospice and Palliative Care: The Push to Admit Every Referral

In the Serenity Hospice Phoenix settlement, Serenity Hospice and Palliative Care agreed to pay $2.2 million over allegations of false Medicare hospice billing. The whistleblower’s complaint described managers who wanted every CareMore referral admitted and a clinical employee who stood in the way by insisting on eligibility. For someone working in admissions, the allegation gets to the decision that matters: whether the patient’s condition or the referral relationship determines who comes through the door.

The Justice Department announced the settlement on October 7, 2015. The hospice fraud case began with a whistleblower who had served as vice president of clinical operations. Her complaint connected management’s instructions with individual patient files, physician certifications and the level of care Serenity billed.

CareMore Referrals and the Demand for a Yes Person

The amended complaint put management’s expectations in a phrase any admissions nurse would recognize:

The complaint alleged money behind that demand. An executive agreed to pay a nurse an extra $1,000 per month until the clinical vice president could be replaced, then an additional $750 per month to handle all CareMore referrals once the position was filled. In the whistleblower’s account, management wanted the referrals handled by someone willing to admit patients even when they were unsuitable for hospice.

The alleged benefits also reached outside the company. The complaint said Serenity’s owner treated CareMore staff to dinners, concerts and limousine rides to keep the hospice in their good graces. The referral-payment allegations thus reached both the source of the patients and the employee handling their admission.

That is what makes the account more revealing than a claim that marketing was aggressive. The whistleblower alleged a management decision to reward acceptance and sideline clinical resistance. The patient’s eligibility was supposed to control the admission. In this account, it had become an obstacle to the referral relationship. Medicare bears the cost when a hospice bills for patients who do not qualify.

What the Patient Files Were Supposed to Show

The complaint alleged contradictions at admission, certification and billing, followed by instructions to complete records afterward. Those are decisions made by different people inside a hospice, and the final claim can hide the disagreement that preceded it.

Hospice eligibility rests on a physician’s prognosis of six months or less if the illness runs its normal course. The complaint alleged that Serenity admitted a patient even though its Consolo software identified that patient as non-terminal. The information questioning eligibility was allegedly already inside the company’s system when the admission went ahead.

For patients, an admission also changes what Medicare covers. A patient who elects hospice gives up Medicare coverage for treatment intended to cure the terminal illness.

The physician’s role mattered separately. The complaint alleged that a Serenity medical director signed certifications as both the hospice medical director and the patient’s attending physician even when he was not that patient’s attending physician. An insider who knows who actually treated the patient can explain something a signature alone cannot.

The whistleblower also alleged firsthand knowledge and documentation of at least 46 patients whom Serenity certified for hospice despite their not having reached the end stage of their illness.

What Are the Criteria for a GIP Hospice?

General inpatient care, or GIP, covers pain control or symptom management that cannot be managed in another setting. Inpatient respite care serves a different purpose: giving the caregiver relief. Those distinctions make the patient’s clinical needs central to the level of care billed to Medicare.

The complaint alleged that Serenity admitted patients to general inpatient care without the documentation needed to explain why that level was appropriate instead of inpatient respite. The allegation reaches beyond whether the patient belonged in hospice. It asks what supported the particular care level the company selected.

Dates and Signatures Added Afterward

The complaint also alleged that officers instructed staff to revisit patient records and complete them:

The sequence matters. An intake entry, a certification and a later scan can tell different stories about what the company knew when it admitted a patient. A finished chart can look complete while leaving that sequence out of sight.

The Founder’s Exclusion and the Company’s Integrity Agreement

Serenity agreed to enter a five-year corporate integrity agreement with the Department of Health and Human Services Office of Inspector General. Its founder and former president, a former nurse, separately agreed to a five-year exclusion from Medicare, Medicaid and all other federal health care programs.

Why an Admission Was Worth Fighting Over

Medicare’s daily hospice payment gives an admission financial value beyond the first visit. The hospice takes responsibility for care related to the terminal illness, while routine home care payment continues for enrolled days. Costs tend to be highest around admission and death, with less intensive care in between.

The HHS-OIG report Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities, published in January 2015, found longer stays and higher payments for beneficiaries in assisted living than in other settings. It explained the incentive plainly:

That national finding explains why control over admissions has economic value. In the Serenity complaint, the alleged extra pay and insistence on accepting referrals put that control in concrete terms: who could say no, who would replace that person, and who would be paid to handle the patients afterward.

The Same Pressure at Another Hospice

Hospice of the Comforter faced allegations that it directed staff to admit all referred patients regardless of eligibility, falsified medical records and limited physicians’ roles in assessing terminal status. The similarity is the pressure on the clinical decision: management allegedly wanted admissions while restricting the people and records that could challenge them.

For an insider, that connects the referral conversation to the patient chart. A marketer may know what a referral source was promised. A nurse may know why admission was questioned. A biller may see the level of care claimed. We work with healthcare insiders and hospice whistleblowers to connect those different views to the company’s instructions and Medicare claims.

The Phoenix Case and the Whistleblower’s Reward

The Phoenix resolution concerned Serenity Hospice and Palliative Care. Serenity Hospice Care in Dublin, Georgia had a separate settlement over alleged claims for ineligible patients.

The Justice Department said the Phoenix whistleblower would receive a share of the settlement payment. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Saw Why the Patient Was Admitted

If you saw referral promises override clinical objections, or patient records completed after the decision to admit, speak with our whistleblower experts. We build the case with you around the patients, payments and management decisions, and bring in hospice fraud whistleblower lawyers who understand eligibility and billing disputes. From the first call, we stay beside you to build your strongest hospice whistleblower case.