Tridia Hospice: Certifications and Examinations in the 2017 Settlement

In the Tridia Hospice settlement, the Ohio provider joined an approximately $19.5 million resolution covering alleged hospice certification and examination failures, excessive rehabilitation therapy and referral kickbacks. The hospice case reached the work behind the Medicare claim: whether Tridia properly certified or examined the patients it billed for. Two former employees brought that part of the story forward.

The Department of Justice announced the resolution on July 17, 2017. It alleged that, from April 2011 through December 2013, Tridia billed for patients who were ineligible for the hospice benefit because it failed to conduct proper certifications or medical examinations. This hospice fraud case concerns the clinical basis for payment, something employees can see long before a bill reaches Medicare.

Who Determines Eligibility for Hospice?

A hospice physician certifies terminal illness, joined for the first benefit period by the patient’s attending physician if the patient has one. Later certifications come from the hospice physician. Medicare requires a prognosis of six months or less if the illness runs its normal course, as its hospice coverage manual explains.

The physician must explain the clinical findings supporting that prognosis in an individualized narrative. The account has to reflect this patient’s condition and the physician’s review or examination. Standard language used for every patient cannot do that work.

That makes hospice eligibility fraud recognizable inside the clinical workflow. The nurse sees the patient, the physician receives information about the patient, and the hospice bills on the certification. What reaches the physician matters as much as who signs. Tridia’s alleged failure concerned the certification or examination needed to support payment for its patients.

How Often Do Hospice Patients Need to Be Recertified?

Hospice patients need a certification for every benefit period. Medicare provides two 90-day periods, followed by an unlimited number of 60-day periods while the patient remains eligible and is recertified. Each new period returns the decision to the patient’s clinical condition.

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

A patient can continue receiving hospice care when the required recertifications support continuing eligibility. The clinical forecast must still fit the patient at each recertification. That is why the supporting examination and narrative matter throughout a stay.

What Are the CMS Face-to-Face Requirements for Hospice Care?

The Centers for Medicare & Medicaid Services required a face-to-face encounter before the third benefit period and each later recertification. A hospice physician or nurse practitioner had to see the patient to gather clinical information supporting continued eligibility and attest that the encounter occurred.

The requirement followed the patient’s cumulative time in hospice, including time with another provider. A transfer could not restart the clock.

Under the certification rules, a nurse practitioner can perform the visit, but only the physician certifies. For staff handling those records, the visit, its findings and the signed clinical judgment are distinct parts of the same payment decision.

Why Continuing Eligibility Matters to the Business

Medicare pays for enrolled hospice days, while care costs tend to be highest at admission and near death. The less expensive middle of a stay can keep producing revenue. Recertification therefore affects both a patient’s care and the provider’s income.

The HHS Office of Inspector General examined that incentive in its 2015 study, Medicare Hospices Have Financial Incentives to Provide Care in Assisted Living Facilities. It found longer stays and higher payments for beneficiaries in assisted living than in other settings, often involving diagnoses requiring less complex care. Its explanation of the payment model is blunt:

When a provider bills for patients whose eligibility it has not properly established, taxpayers pay for care the hospice has not justified. The Tridia allegation focused on the certifications and examinations needed to support payment.

The Employees Behind the Hospice Case

Two former Tridia employees brought the hospice qui tam case. A separate former Olympia Therapy employee brought the therapy action.

Healthcare employees inside a hospice can explain how a clinical record was made: who assessed the patient, what information reached the physician and what management did when staff raised a concern. That view can connect the finished certification to the decisions behind it.

In a separate complaint involving Guardian Hospice, whistleblowers alleged that management wrote patient summaries and fabricated information to support eligibility. The alleged pressure also reached the dates on the records:

In that allegation, staff were being asked to make the paperwork fit billing periods after the fact. An employee who saw the instruction could explain something the completed chart concealed.

Why the Tridia Settlement Covered Three Businesses

The resolution joined allegations across different health care services: hospice, rehabilitation therapy and home-health referrals. HHS-OIG’s settlement summary identifies Ohio-based Foundations Health Solutions, Olympia Therapy and Tridia Hospice Care, along with two executives. The Justice Department’s announcement describes the hospice certification and examination allegations separately from excessive therapy and home-health referral kickbacks.

What Evidence Is Needed to Prove Fraud?

A certification case connects the patient’s condition, the information supporting the physician’s judgment and the Medicare claims submitted for that care. The evidence also needs to show what the provider knew. We examine how those pieces fit together with the employee who understands the work.

The 2019 opinion concerning hospice provider AseraCare examined whether physicians relied on information they knew was false. The 2020 opinion concerning hospice provider Care Alternatives addressed clinical records that an expert said did not support certification. Both put the information behind the signature in view.

An earlier assessment, the version sent to the physician and a management instruction can explain how that information changed. A claim connects the clinical file to the money. That is the work our whistleblower experts do with insiders who recognize a gap between the patient they saw and the record used to keep billing.

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

You Know the Work Behind the Signature

If you saw certifications pass through without the examinations or clinical support they required, talk with our whistleblower experts about the claims that followed. We build your hospice fraud case around that inside knowledge, bring in hospice fraud whistleblower lawyers who understand certification disputes, and stand with you throughout the case.